CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR
ANALYSIS AND BEHAVIOR CHANGE
William M. Hartman
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
To my friends and teachers of the science of human behavior,
Claudia and Hank.
There are so many people to whom I am indebted that in
thanking some individuals, I run the risk of oversight. Two
notable omissions are, however, intentional: I have instead
dedicated this work to them.
I would first like to thank my committee, Drs. Marc
Branch, Mark Goldstein, James Johnston, John Newell, Dorothy
Nevill, and Henry Pennypacker. They provided guidance and
encouragement in a project that had considerable personal,
as well as professional, meaning to me. In addition, I am
indebted to Drs, Calvin Adams and Ogden Lindsley for their
aid in aspects of design and preparation, and to Ms. Vickie
Barkmeier for her invaluable assistance in editing and
preparing the manuscript.
I would also like to thank my entire family for their
unfailing love and support. There is simply no way to even
begin expressing my gratitude to and love for rry parents.
I can, however, thank my mother for her active interest in
and help v/ith my professional career, and my father for his
incredible expenditure of time and energy in preparing the
entire set of graphics for this paper.
Families are not limited to those to whom, one is related.
My thanks to the entire Pennypacker family for the home away
from home they made for me.
There are also two men whose impact on me was profound
and whoffi I wish to rem.ember here, the late Zelig Sered and
I would like to extend special thanks to a special
group of people. I am lucky and proud to have been a part of
the loving, caring team effort that was the STARS Program.
I am particularly indebted to one person. I would like
to thank xMs . Lynda Ward, not only for the time and expertise
she devoted to this work, but also for her support, her love,
and for seeing mie through.
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ......... iii
ABSTRACT ' ^^^
CHAPTER ONE: CASE HISTORIES AND THE PRESENT STUDY ... 1
Case Histories ^
Definition of Case History 2
Earliest Case Histories in Child Development ... 5
Psychological Narratives _ 9
Quantitative Data, Analysis, and Learning
Behaviorism • -"-^
Behavior therapy ..... ^1
Operant conditioning 12
Studies of Retarded Individuals ......... 13
J. M. G. Itard and the Wild Boy of Aveyron .... 16
Claudia: Rationale for and Technical Aspects of
the Case History 20
Technical Aspects 22
CHAPTER TWO: CLAUDIA: A CASE HISTORY OF INTENSIVE
BEHAVIOR ANALYSIS AND BEHAVIOR CHANGE ■ . 26
Background: Claudia's First Seventeen Years .... 26
From Home to the Institution 26
Life at Sunland 27
The STARS Meet Claudia 20
The STARS Program at Lilac Cottage 30
Initial Observations 34
Rumination Baseline • ^"^
Designing the Rumination Procedure 40
Training Begins ^^
Results of the Rumination Procedure 45
Building New Behaviors I: Eye Contact 49
Building New Behaviors II: Playing Catch .... 54
By-products of the Early Training 5 8
Basic Self-Feeding Skills - 60
Learning to Scoop • ^^
Fine Details of Scooping o2
Learning to Walk • 6 9
Preparatory Programs .......... 70
The First Independent Steps 73
Rumination Redxix 7 9
Unmonitored Rumination 79
Procedural Revision . 81
Reversal and Return to Intervention 8 3
Advanced Ambulation Skills 90
Walking Outdoors 90
Auxiliary Skills I: Into and Out of Chairs ... 92
Auxiliary Skills II: Standing Up from the
The Daily Constitutional, Part I 100
The Daily Constitutional, Part II 106
Auxiliary Skills III: Climbing Stairs . 109
Auxiliary Skills IV: Crossing Obstacles 115
The Campus Cafeteria 119
Getting There . 119
Eating Skills in the Cafeteria 121
The Serving Line and Carrying the Tray 12 6
Final Aspects of Training 130
Exploring Out the Gate 130
Expanding the Daily Constitutional 132
Social Behavior 133
The Limits of Training 136
Review of Training Discussed Heretofore 137
Programs That Failed 139
Programs Never Attempted ... 141
Determining the Limits of Training 143
Saying Goodbye 146
The Author Leaves the STARS Program 146
Claudia Leaves Lilac 147
Final Considerations 152
CHAPTER THREE: DETERMINATION OF VISUAL THRESHOLD . . . 154
Method ......... . 156
Training the Basic Response .... 156
Discrimination Training 158
Testing, Retraining, and Retesting 166
Discussion • I'l
BIOGRAPHICAL SKETCH 18 3
Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR
ANALYSIS AND BEHAVIOR CHANGE '
William M. Hartman
December 19 79
Chairman: Dr. H, S. Pennypacker
The cost, effectiveness, and cost benefit of applying a
variety of intensive behavior change procedures were evaluated
in a state residential institution for the retarded. Effec-
tiveness was measured in terms of appropriate changes in res-
ponse frequencies; costs were equated with time and money;
and cost benefit was derived by the cost-avoidance resulting
from the demonstrated increase in adaptive behavior. The study
occurred over a period of approximiately two and one half years
and included over 6000 training and testing hours. The sub-
ject was a nonambulatory, self-abusive, profoundly retarded
female adolescent. Training and/or analysis was conducted
in five areas, as follows:
Decrease of self-abusive behavior (rumanation) : Analysis
of diet indicated that rumination frequency was a,t least par-
tially dependent on liquid density and time of liquid intake.
Changes in these parameters reduced rumination rate from 1.2
to 0.6 responses per minute. Addition of a rumination-con-
tingent lemon juice squirt, followed by a cheek-hold procedure,
decreased the frequency to 0.00 3 ruminations per minute. A
weight gain of 45 pounds accompanied the decrease in rumina-
Ambulation training: The following classes of behavior
were instated (none were present prior to training) : inde-
pendent walking, up to one mile per day at over 100 steps per
minute; independent chair use (into and out of chairs), at 7.0
times per minute in speeded practice trials; ascending and
descending stairs, at 25 stairs per minute; crossing obstacles,
at 6.0 times per minute in speeded practice trials.
Eating and related skills training: Independent scooping
with a spoon was increased from 0.6 to 8.0 scoops per minute.
Use of a cup was taught to terminal performance in practice
trials of 8.0 correct uses per m.inute versus one or zero
spills per five minutes. Training in cafeteria tray-carrying
reduced the frequency with which materials on the tray were
spilled from five times per minute to about once per minute,
at which time totally independent tray-carrying was possible.
Motor skills training: A variety of skills was taught,
including playing catch, with a terminal performance of 70
correct throws versus one wrong throw per ten minutes. Tri-
cycle riding was also trained; assists to steer the tricycle
were decreased from five to less than one per minute.
Assessment of visual f unction irx'g: A modification of the
constant-stimulus psychophysical method was used in a non-
verbal discrimination task involving a white cube (S+) and a
white cube with a black circle (S-) . Lifting S+ and deposit-
ing it in a container resulted in reinforcement, and touching
S- was followed by a brief timeout. The diameter of the S-
circle was gradually reduced from 0.40 cm to 0.0 4 cm. From
the resulting 75 percent correct threshold value of 0.0 8 cm,
acuity ratio v/as calculated as 20/130 (both eyes) .
Periodic follow-ups indicated that most major induced
changes maintained, particularly walking, independent eating,
reduction in rum.ination rate, and weight gain.
Discussion included assessment of factors related to
maintenance of behavior change and a limited analysis of in-
creased social behavior as a by-product of intensive training.
In addition, qualitative and quantitative techniques were
suggested for assessing the relative effectiveness and ef-
ficiency of training procedures and for determining maximal
skill levels in retarded persons.
CASE HISTORIES AND THE PRESENT STUDY
This paper is a report of two and a half years of the
intensive study and training of Claudia, a profoundly retarded
adolescent living in Sunland Center, Gainesville, Florida. •'-
The data included in the report were collected routinely as
part of Claudia's participation in the STARS (Start Training
Appropriate Responses to Stimuli) Program, a training project
funded by Public Law (PL) 89-313.^
The material chronicles behavior analysis and behavior
change efforts in a variety of areas — self-abusive behavior,
motor skills, daily living skills, and determination of visual
acuity threshold — and covers many specific behaviors. Since
the analysis and modification of each behavior was highly de-
pendent on the concurrent existence and rate of many other i
behaviors, the report is best presented in case history, roughly
chronological form, rather than as a series of separate be- i'
havior analyses and behavior modification projects. i
^Permission to use the data reported herein was granted
May 26, 1978. A copy of the release form is on file in the
Training Department Office, Sunland Center, Gainesville, Florida,
^The contents of this report do not necessarily reflect
the views of the Department of Health, Education and Welfare.
The paper is divided into three major sections. Chapter
One revolves around the concept of the case history, tracing
the evolution of the case history in psychology and particu-
larly in behavior analysis. This section considers the rela-
tionship between behavior analysis and behavior change, and
concentrates upon reports of disabled (retarded, autistic,
etc.) individuals. Chapters Two and Three are Claudia's case
history. As indicated above, the material is presented in
approximate chronological order. The case history is sub-
divided according to training milestones, rather than into
time periods of equal length. Traditionally-labeled sections —
"setting," "procedure," etc. — are omitted; all information
that would normally appear in those sections is included in
the narrative account to permit a more readable text.
Definition of Case History
A case history is an account of the intensive study of
some portion of an individual's life. It is usually either
a description of change (rehabilitation) efforts for a problem
or a set of problems, or is a complete description or analysis
of a set of target behaviors. When behavior analysis components
(experimental manipulations designed to establish a functional
relation among stimuli and responses) are included, the term
"case study" may be used. However, the two terms are fre-
quently used synonymously (e.g., Ullman & Krasner, 1965), with
good reason: It is difficult to establish the point at which
description of behavior and behavior change ends and t±ie
experimental analysis of behavior begins (Johnston & Penny-
packer, in press). For present purposes, several comments
will suffice to demonstrate that behavior change/behavior
analysis are best viewed as constituting a continuum; a
particular case history may include data from any part or
parts of that continuum.
The commonest form of treatment described in case
histories involves instituting a change in the subject's
environment and observing whether behavior change follows.
If the behavior changes, especially in the desired direction,
the therapist is likely to conclude that there is a relation
between the procedure and the observed change. The experi-
mental reasoning is weak and clearly belongs at the "behavior
change" end of the continuum. However, for therapeutic pur-
poses the goal has been accomplished. The therapist may also
wish to explore the alleged relation further, for a variety
of reasons and in a variety of ways. The therapist may, for
example, want to test the strength of the therapeutic effect,
examine the degree to which the effect is maintained in
different situations, and demonstrate necessity/sufficiency
of various aspects of the procedure. The therapist's acti-
vities are now shifted toward the "behavior analysis" end of
The case studies described below cover a large portion
of the continuum. The degree to v/hich each m.ay be considered
analytic depends upon the nature of the data — diary,
narrative log, observation schedule, behavioral frequency,
etc. — and upon the "experimental design" employed by the
author. The designs vary by circumstance, ranging from "I
wonder what my client will do if I suggest. . .," to highly
sophisticated and incisive strategies as those described in
research texts (e.g., Sidraan, 1960; Johnston & Pennypacker,
in press) .
No effort will be made to rate the case histories'
analytic value or quantify the continuum. In fact, many
histories lack all but the crudest and most inferential data
and reasoning, but are valuable for other reasons such as
providing pleasurable reading and, occasionally, inspiration.
The role of analysis has become crucial for at least
one group of case history producers and consumers — the group
included under the rubric of "behavior modification" (Kazdin,
19 78) . For this group, case histories of the most analytic
form — studies of individuals conducted explicitly to dis-
cover the laws of behavior — comprise a portion of the
experimental literature. In such experimental studies,
emphasis is generally placed more upon graphic displays of
data than upon narrative account, but the results may cer-
tainly be viewed as case histories. In addition, non- research-
oriented modifiers or therapists regularly integrate various
levels of analysis into their therapeutic endeavors. The
amount and kind of analysis is-- or should be — dictated by i
the needs of the case at hand.
The following sections provide a sample of the scope
and flavor of case histories, and a brief discussion of the
potential and merits of the histories. Heaviest emphasis is
placed upon the role of the case history in behavior analysis,
especially in the training of disabled individuals.
Earliest Case Histories in Child Development
While earlier accounts of the behavior of individuals
are available, Tiedmann's (1787/1927) work is recognized as
"the first attempt to make a series of scientific observations
on the behavior of young children" (Tiedmann, 1787/1927,
p. 206). Tiedmann's goal was to provide data for teaching
"the development of the mind's powers"; he noted that there
was "a dearth of exact and sufficiently numerous observations
upon children's souls" (Tiedmann, 1787/1927, p. 205). To
rectify the situation, he regarded detailed study of the
individual as the best solution, with the following caveat:
I grant that what has here been observed [,
cannot be taken as a general law, since
children . . . progress variously . . . ;
but at least it informs us of one among
the possible rates of progress .... j
When we shall have several such records |
it will be possible by means of compari- ■
son to strike an average for the common
order of nature. (Tiedmann, 1787/1927, :.
p. 206)1 L
Beginning in 1787, Tiedmann observed and "experimented
upon an infant from birth to age two years, six months." His
Ijohnston & Pennypacker (in press) describe the develop-
ment of the view that social phenomena are subject to a
natural law of averages, and the growth of statistics based
on this view.
report was completely narrative and chronological, with
extensive notes concerning the first several days and more '
infrequent observations — about one per several months, as
relevant — thereafter. His data were not quantitative, but
his observations and "experiments" enabled him at least to
begin analyzing behavior. For example, in tracing the
development of the sensation of taste, Tiedmann notes:
Even the special sensations of taste . . .
were not yet distinguished (at two days of
age) .... This appeared conclusively
on August 25. On account of an indisposi-
tion the boy was given a medicine of un-
pleasant taste and pungent odor; he took it
without any sign of objection, like his
usual food. . . . [t] hirteen days after his
birth the boy showed some traces of acquired
ideas, in clearer sensations and affections
of his soul. Some medicines were now un-
willingly taken, with evident reluctance, yes,
were even spewn forth again, but not immedi-
ately, rather upon being tasted several times,
Tiedmann frequently strayed beyond the limits imposed by his
data to draw highly inferential conclusions, looking as he
was for "proof of the superior original activity of the human
soul" (p. 211). Nevertheless, his work was a dramatic, early
demonstration of the potential of detailed study of the
individual; i.e., the case history.
Although Tiedmann 's study was perhaps the first published
attempt at a scientific case history, the educator Pestalozzi
had published a diary several years earlier (1774) documenting
his efforts to teach his young son. While Tiedmann was in-
terested in the description and analysis of various "naturally
unfolding" behaviors, Pestalozzi 's diary was an early prototype
of case histories involving the description of individual
intervention strategies. Although Pestalozzi was not con-
cerned with detailed analysis of his procedures, he carefully
observed the effects of instituting the procedures. He thus
obtained at least a no-intervention vs. intervention analysis:
I left him no choice between his task
[boring, unhappily attended reading
lessons]] and my displeasure with the
consequent punishment of being confined
in a room by himself. After this he
gave way and learned his lessons merrily.
(Pestalozzi, 1774, in Green, 1912, p. 29)
Pestalozzi was also aware-- but did not pursue the study —
of primary reinforcement. He maintained a supply of cooked
apples which he distributed to his son, Jacques, "now and
then." Initially, Jacques wanted to eat all of them at once,
but his father refused, using the opportunity to induce
Jacques to study, telling him, "if he learnt well I would
give him some more. He left the spoon alone," and proceeded
with his lessons (p. 34) .
Pestalozzi 's diary, among his other works, made important
contributions to the field of education. In addition to
providing many examples of effective and ineffective instruc-
tional techniques (he recognized the value of reporting
failure as well as success) , the diary v;as a forerunner of
the many current individual education plans, prescriptions,
Shortly, after Tiedmann's and Pestalozzi 's pioneering
efforts, Itard published the results of nearly five years
of studying and training Victor, the "Wild Boy of Aveyron"
(1801, 1806, translated by Humphrey & Humphrey, 1962). Victor,
v7ho was probably abandoned at about age three to live alone
in the forests of France, was the best-known but not the first-
reported feral child. At least ten such cases were reported
betv/een the mid-sixteenth and eighteenth centuries, and
Linnaeus classified them as a distinct human species. Homo
Ferus (Locke, in Pringle-Pattison , 192 4; Rousseau, translated
by Masters, 1964). However, the early reports of feral chil-
dren were sketchy and unreliable; Itard's several publications
are combined to form the first complete case history of such
a child. First Developments of the Young Savage (1801) and
A Report Made to his Excellency the Minister of the Interior
(1806) combine Tiedmann ' s attempts at scientific analysis and
Pestalozzi's description of educational intervention, to
constitute what is arguably the finest case history ever
written. The work will be considered in detail in a later
section; it is mentioned here to note its place in the evolu-
tion of the case history.
During the remainder of the nineteenth and early twen-
tieth centuries, case histories similar to those described
above continued to appear. Darwin (1877) , for example, pub-
lished A Biographical Sketch of an Infant , a narrative based
on the diary he kept of his son's first six months. The
narrative is quite similar in form and content to Tiedmann 's
earlier work. Singh & Zingg in 19 42 published an account
of Singh's work in the 1920 's with several feral children,
and included a review of the earlier feral cases (Hahn, 1978) .
Diaries and narrative logs thus comprised the earliest
data of the child development field (Arrington, 1939; Mussen,
Conger, & Kagan, 1969; Lytton, 1971). Although behavioral
time-sampling schedules became the most popular method of
collecting data during the 1930's (Hartman, 1978), the case
history remained a major vehicle for detailed study of the
individual. For example, Barker's "psychological ecology"
was centered around the "specimen record," or "narrative
account" (Barker & Wright, 1949) . Piaget also used such
accounts to support his theories of child development,
although narrative records did not comprise the majority of
his data (Flavell, 1963).
The rise of psychoanalysis created great interest in
treatment-oriented case histories or "psychological narratives."
Due to Freud's prolific writing, the case history assumed an
integral place in psychoanalytic literature (e.g., Freud,
1955) . Freud published six case histories based upon various
types of information. "The Wolf Man" was a discussion of
childhood neurosis, stemming from psychoanalysis sessions
conducted while the patient was in his twenties. Another
case history was based upon an autobiography; Freud never saw
the subject. Freud used the case histories as proof of
various aspects of his theories and as a setting for theo-
retical expositions. "Dora" for example, written much like
a novel, demonstrated the value of dream interpretation in
analysis (Jones, 1955).
As the numl^er of psychotherapeutic orientations grew,
so- did the number of applications of the ca.se history. In
addition to appearing in professional journals and books,
case histories and life stories were dramatized and appeared
in the popular literature/ with appeal to professional and
public tastes alike. Dibs in Search of Self (Axline, 1964),
Three Men (Evans, 1966) , Sybil (Schreiber, 1974) , and Children
with Emerald Eyes (Rothenberg, 1977) are recent examples;
their style and popular appeal were foreshadowed by Beers'
autobiographical A Mind That Found Itself (1908).
Quantitative Data, Analysis and Learning Theory
Behaviorism . The foregoing case histories are, with
several exceptions, primarily treatment-oriented and descrip-
tive. The emergence of behaviorism, in the early 1900 's
(Watson, 1924) gave rise to a new type of case history--
studies of individuals that incorporated, or even focused
upon, analysis and/or quantitative data.
Watson and Rayner (1920) , in their famous study of Albert
and the white rat, recorded trial-by- trial progress in
conditioning and generalizing fear. Using similar methods,
Jones (1924) studied and treated another young boy's fear of
various objects. Jones examined the effectiveness of gradually
"fading in" the feared stimuli and noted the degree to which
Peter responded to similar objects not involved in the decon-
Skinnerian psychology (Skinner, .193 8, 195 3) placed
quantitative studies of individuals firmly within the realm of
scientific inquiry. Experimental methods and recording
techniques, developed in the animal laboratory, were soon ap-
plied to the analysis of human behavior (e.g., Fuller, 1949;
Azrin & Lindsley, 1956; Bijou, 1955, 1957, 1958) and continue
to constitute an integral portion of the experimental litera-
ture (e.g., Barrett, 1965; Ferster & DeMyer, 1965; Findley,
1966; Emurian et al. , 1978). These purely analytic endeavors,
published in experimental format, are nevertheless highly de-
tailed studies of individuals. As such, they may be correctly
considered case histories, belonging at the "analytic" end of
the continuum discussed earlier.
Behavior therapy . People involved in the treatment of
behavior disorders quickly saw the relevance of the work of
Watson, Skinner, and other researchers, and applied learning
principles to clinical practice. In the late 1950 's and 1960 's,
Wolpe, Lazarus, Eysenck, Shapiro, and others used case studies
extensively as "proof" of and support for the validity of their
various behavior therapy theories and techniques (e.g., Wolpe,
1958; Shapiro, 1966). Shapiro in particular supported the no-
tion of single-case study for demonstrating therapeutic con-
trol of behavioral disorders.
The early case material heavily emphasized treatment and
did not concentrate upon analysis: No-treatment vs_, treatment
comparison was the common form of case study. For "proof," the
therapists relied upon large numbers of cases, or "reproductions"
of the therapeutic effect. Lazarus (1963) , for example, sum-
marized the results of 125 cases of treatment of severe neurosis.
The relative merits of using this fomn of case history
in lieu of more highly analytic studies, group or single-
subject design, were hotly debated (especially Breger &
McGaugh, 1965, 1966; Rachman & Eysenck, 1966). The most
reasonable conclusion rests upon the degree of analysis
evidenced by a given case history: The studies reported by
the behavior therapists did not offer conclusive proof of the
effectiveness of the therapy techniques employed, but neither
were the cases irrelevant; they were highly suggestive demon-
strations that stimulated more analytic endeavors (Oilman &
Krasner, 1965; Kazdin, 1978).
Operant conditioning . In addition to practitioners of
the behavior therapies described above, another group of
researchers/therapists included by the label "behavior modi-
fiers" are those who have concentrated their analysis and
treatment efforts within the realm of operant conditioning or
Skinnerian psychology. This group, too, has used case his-
tories extensively for analytic and treatment demonstration
purposes. The settings, subjects, and behaviors studied
vary widely. Heaviest concentration has been upon autistic,
schizophrenic/psychotic, and retarded individuals residing in
institutions, but home and outpatient settings for studies
of normal and disabled individuals are not uncommon (e.g.,
Williams, 1959; Rickard, Dignam, & Horner, 1960; Rickard &
Dinoff, 1962; Ayllon & Azrin, 1965, 1968).
The studies have ranged from demonstrative, one-phase
(treatment) -only reports (e.g., Ayllon & Michael, 1959;
Wolf. Risley, and Mees, ]964) to highly analytic research
employing multiple reversals and examination of the target res-
ponse under multiple conditions (e.g., Allen et al., 1964;
Hart et al . , 1964; Rickard & Mundy , 1965; Rekers & Lovaas , 1974).
The most common type of case history is the "AB" or no-treatment
vs. treatment design (e.g., Ayllon, 1963, 1965; Patterson,
1965; Wolf et al., 1965). The scope of the studies has
generally been limited, covering one, two, or three target
responses for periods of about two weeks to a year.
The salient feature of these case histories is the
universal use of graphic displays of quantitative data re-
garding the target responses. WTiether the studies are
written in experimental or narrative format — experimental is
the more common — the graphic data displays are generally the
focus of the reports. The measurement indices vary greatly,
including cumulative records, tallies ,, frequency , and most
often, percent measures — percent time engaged in responding,
percent trials containing a response, etc. The graphic
displays, or more precisely, the data contained in the dis-
plays, make these case histories distinctive among the
histories discussed heretofore in terms of both behavioral
description and analysis.
Studies of Retarded Individuals
Of particular interest to the present report are case
histories and related analyses of the behavior of retarded
persons, particularly the profoundly retarded.
In 1949, Fuller presented the first conclusive evidence
that profoundly retarded individuals — formerly designated
"vegetative idiots"-- were susceptible to operant conditioning
techniques. Fuller's study was not treatrnent-oriented; he
demonstrated that a simple response, arm-raising, could be
controlled by the contingent delivery of food. However, the
implications for the treament of the profoundly retarded
were enormous — subsequent case histories demonstrated that
such basic living skills as feeding, ambulation, and other
motor behaviors could be taught to these persons formerly
regarded to be comtpletely untrainable (e.g. , Rice & McDaniel,
1965; Rice., et al. , 1967; Barton et al. , 19 70; Loynd &
Barclay, 1970). In addition to developing living skills,
researchers and therapists demonstrated control of many of
the undesirable behaviors that frequently accompany profound
retardation: self-injurious behaviors, such as hand biting,
head banging, and potentially lethal rumination (e.g. , Kanner,
1957; Lang & Melamed, 1969; Sajwaj , Libet, & Agras, 1974;
Cunningham & Linscheid, 1976; Harris & Romanczyk, 1976; Iv/ata &
Lorentzson, 19 76; Becker, Turner, & Sajwaj, 19 78).
As is true of the studies reported in the previous
section, case histories of retarded persons range from un-
analytic to highly analytic. The majority are demonstrations
that a particular procedure controls a particular response;
the most common designs are no-treatment vs. treatment (AB) or
no-treatment vs. treatment, with a reversal (ABAB) . While
demonstrating a functional relation between a procedure and
a behavior has been cornmon, fine-grain analysis, such as
isolating the 'specific elements of a procedure responsible
for control, is rare (e.g., Horner & Baer, 1978). For
example, the relevant aspects of overcorrection procedures, ,
popular in controlling self-injurious behavior, are not
known (cf . , Epstein- et al. , 1974; Foxx & Azrin, 1973;
Harris & Romanczyk, 1976). Likewise, some data indicate
that appropriate behaviors emerge as aversive procedures
decrease the rates of inappropriate behaviors, but the con-
ditions under which and the degree to which this occurs are
not well documented (e.g., Risley, 1968; Miller, Patton, &
Henton, 1971). In comparison, there is clear indication
that responses punished under one set of conditions may well
occur at a high frequency in other (no-punishment) settings;
even severely retarded individuals readily discriminate
"safe" and "unsafe" conditions in which to emit the target
behavior (Lovaas & Simmons, 19 69; Rollings, Baumeister, &
Retardation case histories also evidence the same
general scope as do other case histories by behavior analysts,
An "intensive" study might included measuring and modifying
three responses over the course of several months (e.g..
Miller, Patton, & Henton, 1971). There are two notable ex-
ceptions to this generally limited scope. One is Stoddard's
(1971) studies of Cosmo, a profoundly retarded microcephalic.
Stoddard conducted laboratory studies of Cosmo for nearly
ten years in an exploration of behavior analysis teaching
techniques. The studies were generally not treatment-oriented
in that most behaviors were laboratory-specific with no
attempt to generalized to Cosmo's living environment (e.g.,
visual discrimination; token training) .
A second exception to the limited scope of case histories
is Itard's description of the Wild Boy of Aveyron.
J. M. G. Itard and the Wild Boy of Aveyron
Although Itard worked with Victor, " L' enfant savage ,"
from 1801-1806, the work is discussed here because of its
importance to retardation, the experimental analysis of
behavior, and the development of the case history. First
Developments of the Young Savage (1801) and A Report Made to
his Excellency the Minister of the Interior (180 6; both
translated by Humphrey and Humphrey in 1960) together form the
first case history in behavior modification (Lane, 1976).
As will be seen, the work differs from modern behavior
analysis case histories in two respects. First, there is no
graphic display of quantitative data; Itard's reports are in
narrative form with all "data" described in the text. Second,
the technical terminology obviously differs from today's.
Nevertheless, The Wild Boy of Aveyron is arguably the finest
case history ever written in terms of its scope (duration of
training and range of behaviors trained) and in terms of the
full natural integration of training and behavior analysis
to maximize the subject's progress.
Victor was captured in the forest of Aveyron and
brought to Paris in 1800. Authorities, especially Pinel,
estimated his age to be about twelve years and diagnosed his
condition as incurable idiocy (Lane, 1976). Victor initially
created a professional and public sensation in Paris, but the
excitement soon abated since the boy was filthy, unmanageable,
and "differed from a plant only in that he had, in addition,
the ability to move and utter cries" (Itard, 1806/1960, p. 54).
Itard, however, was struck by Condillac's comment that earlier
feral children seemed to possess the intelligence required by
their environments. Based upon this observation and upon the
works of Locke and Rousseau, Itard reasoned that Victor was
largely a product of his environment and that "he had only to
find the proper social and physical education in order to
supply the mental content that would make the boy a normal
human being" (Itard, 1806/1950, p. viii).
Realizing that the weight of current medical opinion
V7as against him, Itard requested and received permission to
care for and train Victor. If the authorities were correct
and Victor proved untrainable, Itard hoped to at least provide
data to speak to the heredity vs. environm.ent question. He
someone who, carefully collecting the history
of so surprising a creature, would determine
what he is and would deduce from what he lacks
the hitherto uncalculated sum of knowledge and
ideas which man owes to his education. (Itard,
1806/1960, p. xxiii)
Itard completely, successfully fulfilled neither aim:
Victor never became a "normal human being," nor did Itard
find a definitive answer to the nature-nuture question. But
Victor did acquire a behavioral repertoire that far exceeded
the predictions of Itard's contemporaries, and Itard did
illuminate the role of the environment in shaping behavior.
In so doing, Itard changed the course of education, particu-
larly for disabled persons. He placed the emphasis of edu-
cation upon the individual, letting his pupil's behavior
determine the course of instruction at every step along the
way. The business of education, he felt, was "detecting the
organic and intellectual pecularities of each individual and
determining therefrom what education ought to do for him and
what society can expect from him" (1806/1960, p. 50).
Itard's description of his work with Victor is fas-
cinating and educational to the modern reader in a number of
respects. Not the least of these is the way that Itard
repeatedly reasoned out and applied behavior management
principles. For example, one of Victor's earliest pleasures
was going out to eat in town. Itard immediately saw the
value of establishing reliable cues for this event and using
them to reinforce behavior:
I was careful to precede our expeditions by
certain preparations he would notice; these
were to enter his room about four o'clock,
my hat upon my head, his shirt folded in my
hand. These preparations soon came to be for
him the signal of departure. I scarcely
appeared before I was understood; he dressed
himself hurriedly and followed me v/ith much
evidence of satisfaction. I do not give
this fact as proof of a superior intelligence
and there is not one who will not object that
the most ordinary dog will do at least as
much. But in admitting this intellectual
equality one is obliged to acknowledge
a great change, and those who saw the
Wild Boy of Aveyron at the time of his
arrival in Paris, know that he was very
inferior on the score of discernment to
this most intelligent of our domestic
animals. (p. 23)
Itard was aware of and used a wide range of behavioral
techniques, now labeled primary and secondary positive and
negative reinforcement, fading, chaining, shaping, and
punishment. He carefully observed the connection between his
procedures and Victor's behavior, and was able to evaluate
both his successes and failures. He was, for example, not
surprised when his initial attempt to punish Victor's food
In order to repress this natural propensity
towards thieving, I made use of chastise-
ments applied during the very act. I
reaped what society generally does reap
from terror of its corporal punishments,
namely, a modification of the vice rather
than a real correction of it. Victor
stole with cunning what until then he had
been content to steal openly. (p. 93)
Of all Itard 's contributions, perhaps the greatest was
the way he used Victor's behavior to restructure continuously
the training sequences. He invariably based a particular
training procedure upon Victor's responses to earlier
procedures. Into this scheme he skillfully incorporated
true behavior analysis, teaching himself the laws of behavior
and using the results of the analyses to remove obstacles
to Victor's progress. While teaching Victor to match objects
with pictures, for example, Itard realized that his original
teaching device might well be inadequate: the pictures v;ere
in a fixed order and Victor might thus be responding to the
order rather than to pictorial aspects of the stimuli:
To reassure myself I changed the respective
positions of the drawings and this time I
saw him follow the original order in the
arrangement of the objects without any al-
lowance for the transposition. As a matter
of fact, nothing was easier than for him to
learn the new classification necessitated
by this change, but nothing more difficult
than to m.ake him. reason it out. His memory
alone bore the burden of each arrangement.
I devoted myself then to the task of neu-
tralizing in some way the assistance he
drew from it. I succeeded in fatiguing his
memory by increasing the number of drawings
and the frequency of their transpositions.
... I soon had material proof by experi-
menting with the transposition of the
drawings, which v^as followed on his part
by the methodical transposition of the
objects. (pp. 39-40)
Itard's documentation of the extensive changes he
produced in Victor thus stands as a model case history for
behavior analysis and behavior change. After five years of
work and despite some limits he could not exceed ( e.g . , he
failed in his numerous attempts to teach Victor to speak) ,
Itard had succeeded in transforming a savage into a civilized
adolescent. From his behavioral methods and his continuous,
informal analysis of the effects of his procedures came a
model for training the untrainable.
Claudia; Rationale for and Technical
Aspects of the Case History
There are several reasons for writing Claudia's case
history. The work is intended to fill a gap in the literature
of behavioral analysis and behavior change. ■ Itard wrote a
treatment-oriented case history of still-unparalleled scope
and detail. Modern behavior analysts and therapists have
added precise, quantitative measurement, graphic displays
and, occasionally, sophisticated scientific inquiry methods.
The scope of these recent efforts has, however, been far
more limited than Itard' s. The present case history is a
combination of these aspects. It is a case history of train-
ing and analysis spanning two and a half years and covering
virtually every relevant aspect of the subject's life, with
each training sequence and subsequence guided, evaluated,
and documented by direct quantitative behavioral measurement.
Its scope is necessarily more limited than that of Itard' s
undertaking; likewise, every procedure employed and response
trained was not subjected to as intense an analysis as has been
seen in the most analytic modern case histories, with an
exception: One aspect of Claudia's training was a largely
analytic endeavor — the determination of her visual threshold.
Since this activity's emphasis was more analytic than
treatment-oriented, the results are presented as a separate
Claudia's case history is the result of the juxtaposi-
tion of an individual in desparate need of intensive training
and a federal grant, P. L. 89-313, that mandated such in-
tensive training. The author was thus able to integrate
direct behavioral measurement and formal and informal be-
havioral analysis techniques to do what he could to help Claudia.
As indicated earlier, all data reported herein were
recorded routinely as part of Claudia's training. In this
sense, the measurement, training, and analysis techniques
used with Claudia were no different than those afforded the
fifty-plus other clients trained by the STARS Program.
Claudia merely received longer and more intense training
than her peers, as she was the first client accepted into
the program and her severe rumination necessitated extra
The data are primarily behavioral frequencies reported
in responses per minute, v/ith several exceptions, such as
weight recordings. ■ The data were recorded by the author
and by full-time STARS Program employees? all data collection
procedures were monitored by the author and other super-
visory STARS staff. With the exceptions of baseline and
other "hands off" periods, data collection generally occurred
during the actual training session — trainers used response-
counters and stopwatches to record the behaviors in-session,
rather than recording in pretest-posttest fashion. To
maximize the accuracy and usefulness of the data, most res-
ponses recorded either produced "behavior products" (see
Johnston & Pennypacker, in press) or else were discrete and
unambiguous. The staff thus obtained accurate data with no
disruption of the training sessions,
STARS data, including Claudia's, are generally recorded
on the Standard Behavior Chart (Lindsley, 196 8; Pennypacker,
Koenig, & Lindsley, 1972). Figure 1 is a typical chart from
Claudia's training folder and represents the core of STARS
record-keeping and training-progress procedures. The trainer
conducting the session recorded the data both on the chart
and in numeric form on a separate sheet. Supervisory staff
checked the charts for accuracy on a monthly basis. Other
records, such as attendance sheets and Sunland campus behavior
checklists, were maintained, but the behavior charts account
for the overvrhelming majority of STARS client information.
Figure 1 highlights conventions necessary to interpret the
data reported in the following sections. The labels at the
bottom of the chart are self-explanatory. Also note that
data are recorded by calendar days, rather than by successive
sessions; the advantages of displaying data against a real
time dim.ension are well-documented elsewhere (see Pennypacker &
Johnston, in press). The primary data are response -frequencies ,
in responses per minute. Dots (•) generally represent correct
or appropriate responses, the frequency of which trainers
attempted to increase. "X's" generally represent incorrect
or inappropriate responses, targeted for decrease. Exceptions
are noted when relevant. Dashes (-) are "record floors" and
denote the reciprocal of the amount of time during which
data were collected. Frequencies of are noted by placing
the data point directly below the record floor. Since the
frequency scale (ordinate) is logarithmic, the combination
of frequency and record floors preserve the entire record —
the distance on the log scale between the record floor and
the 1/minute frequency line is the recording time in minutes;
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s d =
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aifiNisM b3d j-wnoo
the distance between the record floor and its corresponding
behavioral frequency is the response-count. "Phase lines,"
the vertical bars betv;een sets of frequencies, denote changes
in procedure or other environmental changes.
The charts in the case history have been slightly
modified for greater clarity. Horizontal (days) and vertical
(frequency) axes are identical to those on the Standard
Behavior Chart, but the grid has been removed. All charts
have been reduced to conform to editorial requirements. The
charts are otherwise identical to those used and updated
daily in routine client- training operations.
CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR
ANALYSIS AND BEHAVIOR CHANGE
Background; Claudia's First Seventeen Years ^
From Home to the Institution
Claudia was born in Jacksonville, Florida, in November, ,
1958, a healthy seven pounds, three ounces. Her mother had
had phlebitis during the pregnancy, but no other complica-
tions or diseases were noted. There was no family history
At age tv;o months, Claudia appeared to be allergic to
milk, but was otherwise healthy. Her parents began to
worry at three months: she was still healthy but seemed to
be hyperactive and they noticed that her eyes were divergent
and her tongue abnormally large. A month later, the doctor
noted delayed bone development, but it was not consistent
with cretinism. Her waking EEC was nor-mal and several tests
for PKU produced negative results.
The parents continued to be upset. During the following
several months they observed that Claudia neither reached for
objects nor held her bottle. She did seem to notice people
^The information in this section was culled from ad-
ministrative, medical, and cottage records. Details of
Claudia's early training are sketchy and unreliable; hence,
only the barest facts are presented here.
and things and laughed when her parents played with her, but
she did not "socialize" very often. Her movements were jerky
and the large tongue was continuously out.
At seven months, the parents insisted on a diagnosis.
Neither PKU nor cretinism was the problem, responded the
doctor, but Claudia was probably retarded. She was developing
slowly, but not excessively so.
Several months passed, and doctor and parents realized
the child was definitely retarded. They applied for Claudia's
admission to one of the Sunlands, Florida's retardation in-
stitutions. The Sunlands were full, and Claudia was put on
a waiting list. Eight months later she was re-evaluated and
considered for placement at either the Gainesville or Orlando
Sunland. Although she could walk only with complete support,
Gainesville was the appropriate site: the doctor felt she
would be walking unassisted within three years, and openings
at the Orlando Sunland were reserved for cases with more
severe ambulation problems.
In 1960, at age eighteen months, Claudia became one of
the many "retardation, cause unknown" residents of Gainesville
Life at Sunland
There is no record of formal training provided for
Claudia during the next thirteen years. This is not surprising.
The institution was overcrowded and woefully underfunded.
Maintaining basic living requirements for the residents
devoured most of the budget; the remaining training monies
had to be spent on the highest level residents, those able to
benefit from extant teaching and therapy technologies. For
the lower functioning residents, including Claudia, little
could be done; even had training funds been available, these
residents appeared to be untrainable.
Claudia was definitely, as the higher level clients put
it, a "low grade." Her mental age at admission was six
months, I.Q. 32; four years later she tested at mental age 7.4
months, I.Q. 9 CCattell Intelligence Tests). Subsequent
attempts to test her using the Stanford-Binet were recorded
as "FTI" (formal testing impossible) , and she was classified
at the lowest level on the Adaptive Behavior Scale. In short,
she was growing older but developing no new behaviors.
In 1973 she was re-diagnosed as Down's Syndrome. The
diagnosis was only temporary — tests revealed that her
chromosomes were normal. Unbeknownst to her, she was again
"profoundly retarded, cause unknown."
That same year, reports of self-injurious behaviors
appeared in Claudia's records. None of the behaviors —
chewing fingers and toes, occasional head banging, and
rumination (regurgitating and reswallowing food) — were
present when she v/as admitted to Sunland. There is no clue
as to how or why the behaviors emerged.
Shortly thereafter, some formal programming began.
Her records state that she was being trained in "self-help
skills," but there is no account of the regularity, intensity.
or nature of the training. No skills development was recorded.
During the same period, Claudia was assigned a foster
grandparent, Julia. The foster grandparent program provides
elderly people a small supplemental income and was designed
to give the lowest level clients personal attention and a
chance to get outdoors for several hours each day. Although
structured training is not necessarily part of the program, .
a grandparent is often a client's only source of special
attention. Julia thus became a major figure in Claudia's
life, appearing five days a week to take Claudia out of her
cottage in a wheelchair to tour the grounds or sit in the sun.
In 1974, a physical therapist examined Claudia, now 15.
She had never learned to walk, nor could she learn: both feet
were severely turned down and inward at the ankle. She had
learned instead to "scoot," as many clients do; sitting up-
right, she pulled herself forward with her feet, pushing with
her hands. She was admitted to the hospital for corrective
surgery. The triple arthrodesis operation was performed
without complications, and Claudia returned from the hospital
physically capable of walking. But she did not walk. There
was no one to teach her.
A year later, in July, 1975, Claudia fractured her left
tibia. She was placed in the hospital, and there she remained
for several months so that the fracture could heal. During
her stay in the hospital, her rumination drastically increased.
When she returned to Lilac Cottage in November, she weighed
forty-nine pounds, down from her previous high of seventy- three,
This was Claudia as 1975 drew to a close. She was
seventeen, fifty-six inches tall and weighed forty-nine
poxinds. Unable to walk, talk, or in any way care for herself,
she had developed no new behaviors during her fifteen and a
half years at Sunland, except, of course, chewing her fingers
and toes, banging her head, and ruminating; the last was
slowly killing her by malnutrition.
The STARS Meet Claudia
The STARS Program at Lilac Cottage
In late 19 75, federal funds were released to open a new
training program at Sunland. Six of us were hired to create
the "behavior modification component" of grant PL 89-313.
Our grant specifications were flexible; we were to build a
staff of seventeen to work on an individual basis with no
more than thirty- five profoundly retarded clients under
twenty-two years of age. Training was to occur in the areas
of motor, self-care, and social skills; that is, we were to
be behavioral jacks-of-all- trades.
Our supervisor selected Lilac Cottage as the training
site (Fig. 2). It contained girls' and boys' wings and was
reputed to have the campus' highest proportion of appropri-
ately-aged "untrainables"— multiply handicapped, aggressive, ,
and self-abusive clients who needed individual, intense
training that other programs could not provide. Funds to hire
the remainder of our staff were temporarily "frozen" and
money to open our training building was not yet released; so
a week before Christmas we opened our office in the ladies
lounge at Lilac and went to meet our young charges.
Going first to the girls' wing we discovered that the
stereotype of institutions was perhaps not just a stereotype,
The doors v;ere locked to prevent ambulatory clients from
running or wandering away. Within, we found drab concrete-
block-and-tile walls and bare floors; no bright colors or
decorations or toys relieved the monotony. As miuch as the
physical layout was typically institutional, the clients
were even moreso: thirty girls, most of them lying or
crawling on the floor, several v^ho were ambulatory wandering
aimlessly or coming up to grab at us. All of them were
dressed in ragged clothes or ripped gowns. Clothing was for
shredding and toys for breaking-- any free object was for
mouthing and eating. We had tried to choose a population
in need of training. Clearly, we had chosen correctly.
Since there were thirty girls, and twenty-five boys in
the other wing, and our enrollment limit was thirty-five,
our first task was forming a list of priority clients. Test
scores and profiles were of limited value as the clients
ranged from low-I.Q. to untestable and most were labeled
profoundly retarded. The most obvious way to begin our list
was to ask those who best knew the clients-- the cottage
parents, or residential care staff, whose job was to bathe,
diaper, dress, feed and otherwise care for the clients.
They laughed at our first request. All the children
needed anything we could give them. But yes, there was one
girl about whom they were especially concerned. Claudia
had been ruminating more than ever, and they were worried
They pointed her out to us. From a distance she was
not remarkable, one of the smaller figures in white, laying
on her back with knees tucked up about her chest. Walking
over and sitting down beside her, we understood the cottage
parents' concern. Her knees were huge compared to her tooth-
pick legs, her arms were skinnier still, and her ribs showed
clearly through where her gown was ripped. She had shoved
about six inches of a diaper into her mouth and periodically
made a smiall gagging noise, following which a milky vomitus
appeared in her mouth. Half the substance ran down her chin
onto the diaper and gown; she manipulated the remainder with
her large tongue, turning it over while chewing on the diaper.
After about twenty seconds, she sv;allowed and repeated the
It was difficult to determine whether Claudia was
attending to us. Her eyes diverged and we couldn't ascertain
where or if she was focusing. In any case, she made no
attempt to reach for us and altered neither her position nor
her ruminating routine. She evidenced no awareness of our
We examined the remainder of our potential clients and
retreated to our office to begin building our program.
We six were young, fresh, eager — and naive — and in no
mood to await a "go" signal from the state. We had no budget,
nor could we hire trainers, but we could prepare our record-
keeping systems, programming procedures, and the like. And
we could get to know our kids.
Although there was a campus cafeteria, the residents of
Lilac and other locked cottages did not attend. Food was
delivered by truck to these cottages. The cottage parents
dished it and took it on carts to the living wings. At meal
time, we went to the wings and helped feed the clients. We
discovered which clients possessed which skills, learned to
diaper them, played with them, and wondered about the job
we were taking on.
We also knew at least one client with whom we would be
working, and obtaining a baseline record of Claudia's rumina-
tion became our first official project. Designing the data
collection and recording procedures became my responsibility.
My first activity was to observe Claudia's feeding
procedure and get a closer look at her rumination. The
feeding routine rarely varied. Claudia's diet consisted
entirely of "blend," or pureed vegetables, meat, etc., and
Sustacal. Blend was given to clients who didn't chew, and
the Sustacal, a nutrient-rich milkshake-like liquid, was
prescribed for Claudia to com±)at her rumination-induced
weight loss. When the food cart arrived at the wing, a
cottage parent would feed Claudia in whatever position she
was to be found, usually on her back on the floor. The
blend was served in twelve ounce bowls and the cottage
parents fed it to her in a tablespoon as fast as she could
swallow it, about one swallov; every five seconds. Following
the blend, the cottage parent sat her up and fed her a cup
of Sustacal, which she eagerly accepted. Although she
wrapped her hands around the cup, she needed help in holding
it and had to be slowed down-- left to her own devices, she
would open her mouth v/ide and turn the cup upside down,
spilling most of the liquid. The entire procedure took less
than five minutes. As the cottage parent moved on to feed
another child, Claudia commenced ruminating. After watching
the procedure for several meals, I began feeding her. I was
uncomfortable feeding her at her accustomed rate, but this
was my first baseline and I didn't want to disrupt it, and
Claudia certainly didn't object.
During these meals, I was happily forced to correct an
initial impression. The girl was not entirely unaware of her
surroundings. True, most of the time she attended to nothing,
but when the food cart arrived, she looked toward the door.
Upon spotting the cart, she balled up her hands and rubbed
her eyes and nose, making excited gurgling noises. If she
was not first to be fed, she scooted over to the cart, looked
up at it and continued her noisemaking until it was her turn
to eat. If and v/hen we could control the rumination, we
obviously had a powerful reinforcer for other training.
I soon discovered that food was not the only thing that
commanded Claudia's attention. Monday through Friday, at
ten o'clock, the foster grannies arrived. Claudia looked as
they entered the cottage, and she was clearly able to dis-
criminate her granny, Julia. The hands balled up and she
rubbed her eyes and nose; she watched closely as Julia col-
lected a sweater and wheelchair for the daily outing. Once
in the wheelchair and out the door, Claudia calmed down again,
ruminating and attending to little around her. But at least
we were certain that she enjoyed leaving the cottage and that
she could discriminate the source of this pleasure.
Watching Claudia ruminate as she went out with Julia
piqued my curiosity. She seemed to enjoy going out, and it
was her only break from Lilac, yet the ruminating continued.
Before beginning systematic data collection, I couldn't re-
sist playing a little, trying to find an activity that would
reduce the rumination, I talked to her and, poor thing, sang
to her, sat her up and played with her hands, but without
result. I stood her up and v^alked her around the cottage.
She was capable of walking with complete physical assistance,
but she ruminated as well standing as she did on her back.
The cottage parents said she liked balls but had no chance
to play with them as they were among the other clients'
favorite objects to tear and eat. I produced a ball and she
becam.e excited, bouncing it and even attempting to keep other
clients from grabbing it. Here was yet another potential
reinforcer and further evidence of intelligence and motor
control, but still no help for the problem at hand. Ruminating
and bouncing the ball were not at all incompatible.
So much for clever ideas. It was time to quantify the
problem and explore it carefully. But we had learned much from
these first encounters. Claudia responded to things and
people around her. Perhaps eventually we could do more than
try to stop the rumination.
We were in a hurry and wanted to do everything at once.
We had arrived at Lilac two days earlier and were simultane-
ously trying to get acquainted with our clients, develop
assessments, set office policies, and wrest our grant money
and training positions from the state. Nov; Claudia had
caught our attention. We needed to collect the data necessary
to make our first training decisions without disrupting our
grant start-up activities.
As we had neither staff nor time to continuously monitor
Claudia, we chose a sampling scheme. At breakfast and lunch
one of us fed her in the usual manner. Immediately after the
meal, the staff member stood back and counted the ruminations
for five minutes. A staffer returned for five minutes each
half hour thereafter until no ruminations were observed in
two successive samples. The rumdnations were easy to count,
as the gagging noise was clear, the vomitus easily visible,
and chewing was pronounced following each response.
• The rumination followed a regular pattern (Figure 3a) .
Immediately after eating, Claudia ruminated about three times
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per minute and did so for about an hour. Thereafter, the
frequency gradually decreasedf tapering off to near-zero
three to four hours after the meal.
We knew that actual training could not begin until well
after Christmas. We had yet to hire our staff and once
hired, they had to endure two weeks of orientation and
inservice work. We also knew that Claudia was a heavy ru~
minator — her physical condition well attested to it — and
we could see no sense in belaboring the obvious by collecting
weeks of "uncontaminated" baseline. We couldn't train
Claudia but we could manipulate her diet and observe the
effects on rumination frequency.
The Sustacal was a likely place to start. Although the
doctors had prescribed it to keep her alive, we were struck
by the similar appearance and viscosity of the nutriment and
the ruminative vomitus. In the ensuing weeks we fed Claudia
her blend and Sustacal separately; blend an hour before
Sustacal (Figure 3b) , Sustacal a half hour before blend
(Figure 3c) , and no Sustacal until food-induced ruminating
had ceased (Figure 3d) . Vie returned to the original baseline
condition and took stock (Figure 3e) . Although the data were
not convincing, Sustacal seemed to induce miore rumination
than did the blend.
We called the rounds nurse and obtained permission to
replace the Sustacal with water and jello for several days.
We were encouraged by the result (Figure 3f ) . Ruminating
after blend continued, but the water and jello, given an
hour previously, induced little rumination. Fearing the
consequences of removing the extra nourishment from Claudia's
diet, we returned to our original baseline condition and
began planning training procedures. We had never succeeded
in decreasing the overall rumination frequency below one per
two minutes (Figure 4) , but we had demonstrated to ourselves
that we could induce behavior change in our clients. It was
a heartening fact to those of us new to the field.
Designing the Rumination Procedure
While we were manipulating Claudia's diet, the state
released our training positions. We hired our staff and
arranged our schedule. Since decreasing self-abusive be-
haviors was to be a training priority, we devised staggered
shifts covering twelve hours per day, seven days per week.
In this way, clients chosen for intensive training could be
monitored during miOst of their waking hours, including all
m.eal times, and there would be no need to base training
decisions upon small behavioral samples. Claudia and Tammy,
a girl who had pulled out most of her hair and slapped her
face severely, were to be the clients to receive twelve-hour-
As we awaited our trainers' return from their orientation
activities, we assessed the results of Claudia's baseline and
considered possible procedures for decreasing the rumination.
We wanted first to restructure the mealtime environment.
Even though Claudia had demonstrated that she would ruminate
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V7herever she found herself, v^'e thought that ^ more closely
controlled setting than the floor of the cottage day room
would foster more effective intervention. Our program owned
several pieces of equipment purchased with early grant
funds. One of the purchases was a small wooden relaxation
chair commonly used by physical therapists. It was perfectly
suited to our needs. The adjustable head rest and clip-on
tray would allow us to feed Claudia in an upright position
and would restrict her movements without discomfort. We
could watch her closely for post-meal rumination. The ap-
paratus was mounted on wheels, giving us the option of
feeding her in the bedroom area or hall, away from her usual
location without having to drag her into and out of a
We also agreed that it would be wise to slow down her
eating. Most of the clients ate rapidly, whether feeding
themselves or fed by the cottage parents; the fast eating
did not seem to induce rumination. Still, Claudia did not
rumiinate while she ate and perhaps increasing the duration
of the meal and decreasing the rate of food intake might
help slow the rumination. We watched one another in the
campus cafeteria and concluded that one bite per fifteen
seconds -v^as a reasonable rate.
The Sustacal posed a tricky problem. Our data suggested
that Claudia ruminated less without it, yet it constituted
a major portion of her nourishment and possibly was keeping
her alive. While we pondered the medical and financial
feasibility of various powdered food additives, one of the
cottage parents offered a far simpler solution. Why not mash
peanut butter and jelly sandwiches into the blend? The result
might not be esthetically pleasing, but neither was the blend
alone, and Claudia was hardly a gourmet. The peanut butter
was rich in protein, the whole sandwich might put weight on
her, and the thick, gooey product certainly looked harder to
ruminate than did Sustacal. The rounds nurse readily granted
approval. We could eliminate the Sustacal, replacing it
with our concoction. Water and jello before the meal would
ensure adequate liquid intake. We would be alerted to any
problems arising from the new diet, as we had been weighing
Claudia almost daily since data collection had begun.
We were not satisfied. Our planned procedure v/ould
probably reduce the rumination but almost certainly not stop
it. We could foresee a temporary decrease in the rumination
frequency, followed by a gradual increase as Claudia adjusted
to her new diet and feeding environment. Any other training
we might try would be hampered by and possibly enhance the
rumination. We therefore sought assistance from published
cases of rumination treatment.
We located two strategies, response-contingent electric
shock (Lang St Melamed, 19 69) and response-contingent squirts
of lemon juice (Sajwaj, Libet, and Agras, 1974). Shock was
out of the question. No one had ever systematically tried
to stop Claudia's rumination, and to begin with such a painful
procedure would be irresponsible and unfair to Claudia. In
addition, Florida's retardation system operated under a set
of behavior xnanagement guidelines that clearly forbade the
use of shock.
Using lemon juice was feasible. A trainer could use a
laboratory wash bottle to squirt a small amount, one cc or
less, onto Claudia's tongue each time she attempted to
ruminate. The attempts were easy to spot. The gagging noise
reliably preceded each appearance of the vomitus and we could
thus "catch her in the act," increasing the likelihood of
Our final preparatory step was to present our baseline
data and planned procedures to the campus behavior management
committee. At the time, even using lemon juice was of ques-
tionable status in the behavior management guidelines and
required the approval of campus administrators and consulting
professionals. Moreover, behavior modification was a newcomer
to the campus and its practitioners were closely monitored.
Permission was granted and we were ready to begin.
Several years later, a colleague asked me why — after I
had independently assessed at least several elements of our
procedures during those first weeks — I chose a "kitchen
sink" treatment. The relaxation chair, the spaced feeding,
the diet changes, the lemon juice,' all at once; it was
hardly a systemiatic approach to the problem. Granted, it
was not. But it was our program's first project and v;e were
testing our competency as behavior change agents. For the
Sunland campus, it was a test of a new kind of training.
intense, individualized, and based directly upon behavioral
data. Most importantly, it was our chance to help Claudia.
She did not know us; we had done little except observe her
rumination. But we were getting to know her and wanted to
help. We planned to use every tool at our disposal to do so.
Results of the Rumination Procedure
On February 5th, Claudia ate her breakfast as she
usually did, on the day room floor. She spent the morning
ruminating while Marsha — the trainer I assigned to Claudia —
and I passed the time fretting, pacing and reviewing pro-
cedural details. At lunch time, Marsha brought in the
relaxation chair. We seated Claudia and wheeled her into the
bedroom area. Marsha placed herself opposite Claudia and
arranged response counters, stop watch, the gooey mess that
was lunch, and the wash bottle of lemon juice. The feeding
went smoothly and we even observed an extra benefit. The
sticky peanut butter, harder to swallow than blend, helped
pace the food intake. Claudia was hardly fazed by our tension
and the nev7 setting and diet. Soon after lunch we heard the
first gag. Marsha was ready and delivered the lemon juice
accompanied by a stern, "No, Claudia!" The intervention
startled Claudia and she jerked her head away. She ruminated
again, and again Marsha was ready. The attempts to ruminate
dropped abruptly and within an hour we were able to take her
out of the relaxation chair. We seated her in the cottage
lobby- to watch her and be ready with the 'lemon juice until
v;e were sure ruminating had ceased for the afternoon.
At dinner we repeated the procedure and were again
successful. Claudia had begun the day ruminating at her usual
rate of one to two per minute. With our procedure in place,
the rate dropped to about one in seven minutes, an eightfold
decrease. We went home that night elated but concerned.
Would the effect last or was it merely due to the novelty
of the procedural barrage?
The next day indicated that it was not. The ruminating
rate remained low. After breakfast, trainer and lemon juice
accompanied Claudia and Julia on their daily excursion.
Julia had watched Claudia vomiting herself to death and had
helped us during baseline data collection. She and the other
foster grandparents shared our excitement.
On the third day, the ruminating rate declined to one in
twenty minutes; by the fourth day it was one in fifty. Within
a week, Claudia had gained five pounds and was ruminating at
one one-hundredth her original rate. The rate stabilized
(Figures 5, 6a). Within two months we were able to give her
her liquid after meals, with no increase in rumination.
With the rumination under control, Susan, Claudia's
morning trainer, decided to find out v/hat Claudia liked to eat.
We had purchased a variety of candy and snacks for the clients
and Claudia vjas entitled to her share. I arrived at work
one morning to find Susan upset. If Claudia had to put up
with the unsightly blend because she couldn't chew, why was
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she so adept at crunching potato chips? I didn't know.
Neither did the medical staff, so we replaced the blend with
regular meals , still supplemented by peanut butter and jelly.
Claudia continued to gain weight (Figure 6b) . During
the next several months, we eliminated the peanut butter and
jelly sandwiches one meal at a time. Much later, we had to
put her on a diet and remove fattening desserts. We looked
back at the early weight records and laughed.
Building Nev; Behaviors I: Eye Contact
In our concern over her rumination, we had given little
thought to what V7e might teach Claudia. Several days had
passed since we had begun rumination intervention and her
trainers now had little to do but watch her. We did not
dare return her unattended to the cottage day room for fear
the rumination v/culd regain its previous rate. Claudia
possessed a limdted behavioral repertoire and by reducing
the rumination we had left her with almost nothing. Where
to start building?
"Attention span" was a logical prerequisite for training.
Eye contact with the trainer was widely regarded as the first
step in establishing visual attending behavior (Kozloff, 19 73;
Foxx, 1977). In addition, it seemed that recognizing one's
name was a necessary, basic skill, one that Claudia did not
possess. We had never seen her respond to her name or to
anyone's voice. Only loud noises and the sound of the cottage
door and rolling food cart seemed to attract her attention.
We resolved to teach her to look at us when we called her
To ascertain that she did not, in fact, knov7 her name,
we began with a baseline procedure while she sat in her
relaxation chair before meals. When Marsha was sure that
Claudia was not looking at her, she would say, "Claudia,
look at me" and record whether Claudia's eyes met her own
within five seconds. Marsha continued in this manner for
five weeks, about two minutes per session, and obtained
relative frequencies of looking and not looking. During the
first three weeks, Claudia rarely responded. Over the next
two v/eeks, she began to make eye contact more frequently,
but during only one session did she respond appropriately
more often than not (Figure 7, phase A).
We reasoned that if we continued in this way, Claudia
might eventually learn to respond consistently to Marsha's
voice. However, we wished to teach her more rapidly. We
required Claudia to earn part of her meal by making eye
contact. The procedure was similar to the previous one,
except that it occurred during the first part of the meal.
Marsha timed and counted the eye contacts, giving Claudia
a spoonful of food on a continuous (CRF) schedule, one
spoonful for each success. After Claudia had earned twenty
spoonfuls, Marsha fed her the remainder of the meal. We had
observed previously that Claudia's eyes invariably follov/ed
the spoon during feeding. Vie used this finding to institute
a "fading" procedure (e.g., Whaley & Malott, 1968; Bassinger
et al. , 19 71) : Marsha began the training with the spoon
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directly in front of her eyes and over the next two and a
half v^eeks gradually lowered it to plate level ("faded out"
the spoon) while maintaining eye contact (Figure 7, phases 3,
C) . After four and a half weeks the behavior was stable, but
how long it had taken to teach such a simple response! Hank,
my graduate advisor, was visiting one afternoon when Claudia
was massing more responses than usual. I told him that I
knew retardation training would be slow and painstaking,
but until now I hadn't understood the definition of "slow."
It was only the beginning.
We had achieved some measure of control over the eye
contact at mealtimes, and extending this skill to other
situations seemed imperative. We must continue to use food
to reinforce the behavior, that much was clear, but extra
feeding between meals might increase the nomination. We
opted for small bits of food, marshmallows and raisins, and
conducted the session about an hour before meals. The effect
was immediate. We lost our hard-won gains (Figure 7, phase D)
Was it the change in session time, or was it the m.arshmallows
and raisins? l-Jhen she discovered Claudia could chew, Susan
had observed that Claudia would eat almost anything but was
more excited by her meals than by the snacks. We replaced
the marshmallows and raisins with small spoonfuls of blend
and regained control of the eye contact (Figure 7, phase E) .
We had lost control of the eye contact for a week, but our
data were instructive: Candy has been widely used as a
reinforcer, but our chart indicated that it would not
reinforce Claudia' s. hehayior. It v?as nice to know that she
preferred nutritious substances to junk food, a finding
that maintained throughout her training.
V7e varied position and distance of the trainer relative
to Claudia, and began rewarding the eye contact with blend
on a variable ratio (VR) 2 schedule, about one spoonful for
each two appropriate responses (Figure 7, phases F, G) . At
the end of the project, Claudia always raised her eyes when
we asked her to look at us.
But we had failed in several respects. First, we did
not teach "eye contact" with emphasis upon "contact." It was
clear that Claudia was not looking at us. Rather, she had
developed a cute, stereotyped response, eyes raised to about
the level of our eyes, gaze fixed, mouth slightly open to
receive the food, head cocked to one side. The fixed gaze,
sometimes a shade above or below our eyes, let us know that
she was not really looking at us. Second, she had not
learned her name, nor did she respond to our voices except
in a training situation, with spoon present. We could have
continued the project, gradually increasing the ratio of
responses to food, but to what avail? We couldn't modify
the stereotyped responses.
We gained much from this project, though. We had built
a behavior, even if not exactly the one we had intended,
where there was none before. Claudia could learn new skills.
We also learned that "attention," or at least attention as we
viewed it, was not a necessary first step in training. Her
progress in other areas without it would subsequently confirm
that fact. She did begin to respond to her name and to really
look at us, much later, as a by-product of the thousands of
hours v;e worked with her. The "basic skills" turned out to
be complex achievements.
Claudia has never lost this first response she learned.
Over the following two years the response would appear again,
when we were trying to teach her new skills and having trouble,
She would frequently raise her eyes and assume her old ex-
pression, as if following the rule, "when all else fails,
try eye contact." That facial expression became dear to us.
Building New Behaviors II: Playing Catch
After meals, Claudia's trainers generally gave her a
soccer or large plastic ball to bounce while they monitored
the rumination. She entertained herself this way for hours.
When her trainer brought out the ball immediately after the
meal, she grew excited. If the trainer bounced the ball
before giving it to her, she frequently bounced in her seat
V7hile watching. But once she was given the ball, she rarely
We saw here an opportunity to interact with Claudia
in a purely social manner. Teaching her to play catch might
also give her a skill she could use on the cottage with other
clients. And it was our first opportunity to play v/ith this
girl who knew us only because we fed her and scolded her
when she ruminated.
Her trainers tossed her the ball from about four feet
av7ay , clapping their hands and telling her to throw it. If
she threw or bounced it back;, the trainers counted a correct
response. If she threw the ball in the wrong direction or
failed to throw it at all within ten seconds, the trainer
retrieved it and tried again, counting an inappropriate
response. When we started, she returned the ball to us about
half the time. In only four weeks, we all but eliminated the
correct responses (Figure 8, phase A). Most of the time she
threw it in the wrong direction, frequently over her shoulder.
Perhaps she was responding to terminate the game or to watch
us chase the ball. Either way, this was not our idea of a
We reviewed the situation and made note of the following:
First, we were sure that playing with the ball was a rein-
forcer. Before we had begun the catch program, Claudia
reliably grew excited upon presentation of the ball and
quickly retrieved it if it rolled away from her. She played
with it for seemingly endless periods of time; this was a
high-rate behavior and therefore a potential reinforcer
(Premack, 1965). Second, we recalled the well-established
findings that satiation decreases the effectiveness of rein-
forcers and deprivation increases reinforcers' effectiveness.
Prior to our interaction with Claudia, she rarely had access
to balls; she now had access to them for several hours per
day in addition to the catch-program time. We might well be
observing the effect of satiation. If so, we would do well
to create instead a state of deprivation by limiting her
access to the ball. Finally, we analyzed the consequences we
had arranged for the game of catch. When Claudia responded
correctly by throwing the ball to us, we threw it back,
continuing her access to the reinforcer. Hov^ever , inappro-
priate throv/s resulted in almost the same consequence — we
retrieved the ball and threw it to her again. A widely-used,
highly successful method of reducing inappropriate behavior
is "timeout," the brief withdrawal of a reinforcer contingent
upon the undesired response. Perhaps such an arrangement —
briefly limiting access to the ball after incorrect throws —
would be an effective consequence.
Based on our analysis, we changed the rules of the game
so that she would play our way or not at all. We only gave
her access to the ball during sessions. If she threw it in
the wrong direction we stopped the game for two minutes (the
stopwatch did not run during this time) . If she threw it in
the wrong direction twice in succession, we terminated the
game and did not play again until after her next meal.
It was hard to enforce the new rules. We were growing
fond of Claudia and playing with the ball was the only thing,
except eating and going out with Julia, she liked to do. We
did not like to take away the ball, but we were determined
to teach her to play with others. Most of her fellow clients
seemed to enjoy our attention, and we were spending more
tim.e with Claudia. Besides, we didn't enjoy chasing the ball
around the cottage.
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We '.hung on and slowly, imperceptibly, she began to play
(Figure 8, phase B) . After eleven weeks, we terminated the
procedure, or rather she terminated it. She would throw the
ball as long as anyone was willing to play with her and she
wore out trainer after trainer. We gave her free access to
the ball again and the choice was hers. If she wanted to
play, we'd play, but we were grateful for the rest when she
bounced the ball by herself.
Trainers who have resigned return to visit the program
and usually play catch with Claudia. It's easy to buy her
a present she will appreciate, and she owns a truly impressive
assortm.ent of balls.
By-Products of the Early Training
Claudia's success in her new programs bolstered our
confidence. We had begun the eye contact and ball-toss
sessions simultaneously, within a week after starting the
rumination intervention. The rumination rate remained low
v/hile Claudia acquired her new skills. Most of our staff
worked with Claudia at one time or another, and we were all
excited and proud.
But in early spring, the staff had some bad news for
Marsha, Georgianne, and me, the people responsible for her
training. "Your baby," they told us, "is spoiled rotten."
We couldn't deny it. Before training began, Claudia had
lain passively on the day room floor, growing excited only
when Julia or the food cart arrived. Now there were occasional
tantrums if her trainer arrived late for her meals. She would
cry and rock forward, sometiines banging her head on the floor.
We were not worried about these tantrums, they seldom hap-
pened and the head banging occurred only rarely. Usually,
she merely rocked, her forehead stopping inches from the
floor. Occasionally she hit it and looked at us, commencing
to cry. At least she knows us, we thought. The tantrums
did not become a problem. We generally arrived before the
food, and if a tantrum was in progress we did not begin her
session until she was quiet.
A more pressing problem was after-meal tantrums. We
were still keeping her in the relaxation chair for a brief
period following each meal, the crucial time for rumination.
We were reducing this chair time, but evidently not fast
enough for Claudia. She began screaming and crying, jerking
around in the chair. We did not want to take her out once
she started crying and risk teaching her to misbehave.
Neither could we use an "extinction" method, that is, simply
ignore Claudia until the tantrum ceased. Her behavior was
more violent in the chair than during premeal tantrums and
we were afraid that if we ignored her, she'd hurt herself
while destroying the chair.
We simply could not let the tantrums begin. I took
advantage of the chair's mobility, rolling it up and down
the hall soon after she finished her m.eal. I could keep a
close eye on her in case of rumination and she seemed to
enjoy the ride; she gave me one of her rare smiles. I pulled
a little faster, she smiled more. The weather was turning
pleasant, so I rolled her out of the cottage and we v^ent
tearing up and dovv-n the sidewalk. She laughed long and hard,
and won our hearts.
Basic Self-Feeding Skills
By early April we had a name for our program, STARS
(for Start Training Appropriate Responses to Stimuli) , a new
training building, and a budget. It was spring and a time
for change .
Marsha, George, and I grew more ambitious with Claudia's
training. She had shown herself capable of at least simple
skills, given time, patience, and careful monitoring by
those who worked with her. Virtually everything had to be
done for her and we wished to help her acquire more inde-
pendence. The two areas that appeared to offer the best
beginning were feeding and ambulation. Although her move-
ments were jerky, Claudia v;as not spastic, so independent
feeding did not seem an unreasonable goal. The triple
arthrodesis operation several years earlier had left her
physically capable of walking. We tackled both problems
Learning to Scoop
Teaching Claudia to feed herself was perhaps the most
initially promising and eventually frustrating project we
attempted. She acquired the basic skill, independent
scooping, more rapidly than anything else we taught her.
Polishing the basic behavior and adding related skills was
an incredibly slow process and we met with failure more
We began, of course, in the relaxation chair at meal-
time. The chair was as ideal for teaching feeding as it was
for monitoring the rumination. She sat straight and the
clip-on tray was at a comfortable height. As much as she
loved to eat, we knew she would be highly motivated to learn
this new skill.
She had no trouble holding a teaspoon loosely in her
fist, but we were unable to induce her to hold it as one
usually does, between the index and third fingers with thumb
on top. However, we had observed many clients feeding them-
selves using a fist-grip. It was more awkward than a normal
grip but it seemed to get the job done. We considered our-
selves to be lucky that Claudia held the spoon at all without
prior training and we accepted the fist-grip. Her grasp was
not strong, however; so we began the program with a built-up
spoon, a commercially available product that has been suc-
cessfully used to teach feeding skills to the profoundly
retarded (Miller, Patton, and Henton, 1971) . The handle of
the spoon was a plastic cylinder three-quarters inch in
diameter. This Claudia held firmly enough.
The procedure was simple. For the first few trials, ,
Marsha wrapped her hand around Claudia's and guided her
through the entire motion, lowering the spoon, loading it
with food, and raising it to her mouth. Marsha felt little
resistance from Claudia's arm; the movement was smooth and
natural. Marsha next released her hand and Claudia, with
soroe difficulty, successfully loaded the spoon and fed
herself. Claudia was awkward but persistent and Marsha did
not intervene on a given scoop until it became clear that
Claudia would not succeed on her own. When such was the case,
Marsha took Claudia's hand and finished the scoop with her.
Claudia was free to try alone on the next scoop. The first
day, Claudia scooped without assistance in one of every four
attempts. In little more than _ a week she was scooping entirely
independently. We allowed her to continue in this manner for
several more weeks to gain proficiency. On the first day of
training she had scooped independently at the rate of once
per two minutes. Her speed rapidly increased to about eight
scoops per minute (Figure 9 , phase A) .
Once again, Claudia had come through for us. For
seventeen and a half years she had been fed and within a few
weeks was able to scoop on her own. It was so easy. We
planned to put on the finishing touches, to teach her to
use a regular spoon and to eat more neatly so that we could
remove her bib. We were to be surprised and disappointed.
Fine Details of Scooping
Although she was scooping rapidly and without assistance,
Claudia was making a mess. She had added a new component
to the scooping movement, rolling her wrist as she lifted
the spoon to her mouth, taking it in upside down. Much of
her diet v/as soft and sticky and adhered to the spoon, but
the remainder landed on her bib, the tray, and the floor.
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We had not intervened as the behavior developed since we
did not wish to interfere with her independent scoops.
We concentrated on the wrist rolling. Her grasp was
firmer nov7, and we replaced the built-up spoon with a regular
teaspoon, the handle of which we covered with friction tape
to prevent slipping. We temporarily discontinued monitoring
the unassisted scoops and began assisting her again, cor-
recting position of spoon and wrist. We were not successful;
we were unable to decrease the frequency of assistance
(Figure 9, phase B) . We also had to intervene in other ways.
She was taking larger and larger spoonfuls. At one point,
she lifted her entire portion of mashed potatoes and at-
tempted to get them all in her mouth. She was as likely to
scoop the food from her bib or the tray as she was from the
plate. We began blocking the large and off-plate scoops,
each block accompanied by an assist to initiate a correct
scoop. We were unsuccessful again (phase C) . At least, we
consoled one another, she never attempted to use her fingers,
even when struggling to scoop a small morsel from the corner
of the plate.
We decided to begin afresh, to build a new scooping
movement. For several weeks we held her wrist on every scoop,
guiding her entirely through the motion. Then we gradually
allowed her to scoop independently, increasing the frequency
of unassisted scoops until they accounted for 75% of the
total (phase D) .
The frequency of large scoops was decreased and the
wrist-rolling was gone. Gone also v;as the tape on the spoon,
worn off by repeated washing. Her grip was solid so we did
not replace the tape. But now there was a new problem. She
had begun scooping backhanded, shoving most of the food off
the rear edge of the plate. We repeated our strategy, be-
ginning with complete assistance and then allowing increasing
numbers of independent scoops (phase E) . Before she had
even achieved one independent scoop per minute, her backhand
returned. Again we assisted her entirely, then relaxed the
assistance, and again she back-scooped (phase F) ,
We did not know what else to do. We considered several
strategies and rejected them. Many more ideas, of course,
present themselves in hindsight. But we coped with the
problem in our usual manner. We returned to complete physical
assistance, this time for several months (Figure 9, phase G) .
Many changes occurred during this period. Claudia began
eating at the campus cafeteria as a result of her progress in
other training sessions. The change in scenery did not help;
occasional probes revealed that the backhanded scooping would
reappear if given the chance. None of us could think of a
way to m.odify the behavior.
In January, 1977, more out of frustration and discourage-
ment than out of any change we observed in Claudia's behavior,
we changed the procedure. We allowed her to scoop indepen-
dently, blocking and re-directing any attempted backhand
scoops. She immediately regained her original independent
scooping rate of eight per minute. We had to assist her just
over once per minute and elected to wait and see what hap-
pened (Figure 9, phase H) . Over the next seven months, the
rate of assistance decreased to about once in five minutes,
or several assists per meal.
We had, I suppose, succeeded. But the behavior change
was small in relation to our expectations. We nevertheless
continued to work on her feeding skills, meeting with success
in some attempts and failure in others. Had Claudia not
shown such remarkable progress in other areas, we would have
been thoroughly discouraged.
Learning to Walk
While Claudia's progress in her feeding programs was
slow and often discouraging, helping her acquire ambulation
skills rewarded us often. Progress was rapid at tim>es and
slow at others. The training frequently bogged down and was
then revitalized by a sudden breakthrough. We had to face
limits in some areas while in others she continued to grow.
Teaching her to walk provided both the most challenging and
gratifying experiences we had with her.
We had been considering teaching Claudia to walk from
the time v/e began working with her rumination. She had
undergone the operation to repair her feet, giving her the
physical capability to walk. Examining the conditions under
v^hich she ruminated, I had discovered that she would walk
short distances if I held her hand tightly. However, the
rumination caused us to delay the start of formal walking.
We wanted first to bring the rumination under control and
effect a weight gain, as we were afraid that her pathetic
legs could not withstand any strain. While we waited, we
began several preliminary programs to assess her current
capabilities and to exercise her legs.
The day after rumination intervention began, we started
walking Claudia for a minute or two at a time, several times
per day. Her trainers held her hands tightly but made no
effort to force her to walk. She walked at a rate of fifty
to eighty steps per minute, sitting down every fifteen to
twenty seconds. Her steps were small, each covering about
eight inches. They were not uncertain, clearly steps and
not shuffles, but they were jerky and she swayed from side
to side. This peculiar gait may have been due to the fact
that she never developed hip rotation. The swaying motion,
while greatly reduced, has never disappeared and one can
always spot Claudia walking, even at a distance.
For additional exercise we had her push an empty wheel-
chair. Her trainers walked behind her, keeping her hands
firmly on the grips. She walked slightly faster with the
wheelchair, between ninety and one hundred steps per minute.
However, we abandoned the program within two weeks as keeping
her hands on the chair was a problem and the trainers had
trouble positioning themselves, leaning over her to maintain
contact with her hands.
Walking provided only several minutes of exercise each
day and we did not feel that this was adequate. Although it
was winter, it was frequently warm enough to go out during
the afternoon, so we tried our luck with a tricycle. A
trike would exercise her legs for about ten minutes at a time
without straining her. Not her, perhaps, but it certainly
strained us. Claudia would not keep her feet on the pedals.
We tried built-up pedals, straps, and pedal stirrups, but
with a wiggle or two of her feet she undid our best efforts.
Several shoe laces tied end to end finally served the purpose.
Enough loops and knots and twists and turns, and her feet
remained firmly planted on the pedals. At first it took two
of us, one to balance her on the seat and one to perform the
elaborate tying-on ritual. When she became accustomed to
the trike, she helped by sitting still and only one trainer
VJith her obviously limited tricycling experience, we
were not surprised to find that Claudia did not pedal. For
three weeks we pushed her. The rotating pedals stretched
and flexed her legs, giving them at least some exercise. In
the middle of March, we noticed that we didii't have to push
as often — Claudia was doing some of the work too. We counted
assists to move or steer, initially providing assistance almost
six times per miinute (Figure 10, phase A). Three weeks later,
when we began her form.al walking programs, we v/ere still
assisting her at this rate, but there had been several days
during which substantially fewer assists V7ere necessary.
SxnMM B3d INHOD
The tricycle h,ad served its original purpose in that it had
given Claudia exercise preparatory to walking. But these
first signs of success on the trike encouraged us to continue
the program as an added form of recreation. We maintained
the program only sporadically, but Claudia slowly improved.
At the end of July, we happily dispensed with the shoelaces,
and she kept her feet on the pedals (Figure 10, phase B) .
A year and a half later, Claudia graduated to a bicycle
with training wheels. She pedaled with nowhere near the
proficiency required to eliminate the training wheels, but
we V7ere satisfied. We had set out to give her exercise, and
she had learned a new recreational skill in the process.
The First Independent Steps
We began formal walking sessions in early April on the
same day we began teaching Claudia to feed herself, and
precisely two months after we began rumination intervention.
She weighed sixty-six pounds, seventeen pounds more than when
we met her, and we had observed no problems during her pre-
vious exercise programs. She seemed ready to walk alone.
We took her into the long hall that connects the girls'
and boys' wings and let her sit on the floor, I sat beside
her and showed her a cup with several sips of fruit juice in
it. She became excited as she always did, rubbing her eyes
and nose. I stood, walked back about eight feet, and stopped,
always keeping the cup in plain view. She watched intently.
From behind, Georgianne placed her hands in Claudia's armpits,
lifted Claudia to a standing position, and walked her forward.
About four feet in front of me, Georgianne let go. Claudia
walked — more precisely, staggered — her first independent
steps to my arms and her juice. We repeated the procedure
and again she walked the last few steps alone. We were
Then, caught up in the excitement of the moment, I erred
badly. i wanted to see how far she would walk by herself.
On the next attempt, I began walking backwards as she ap-
proached me, keeping about one and a half feet between us.
She followed me for perhaps twenty feet, stopped abruptly,
and sat down. I had pushed her too far. The sudden, drastic
increase in the number of steps required for a sip of juice
had probably extinguished the walking: Claudia had responded
appropriately, I had failed to reinforce the behavior, and
the walking disappeared. In such situations, merely requiring
less work for each reinforcer is usually sufficient to re-
instate the behavior (Reynolds, 19 6 8; Krumboltz & Krumboltz,
We therefore tried again, only this time I had no inten-
tion of moving. A few independent steps would have satisfied
me. None were forthcoming. As soon as Georgianne started to
remove her hands from the armpits Claudia went down. Nine
m.ore attempts produced the same result. I was furious with
myself. Weeks of preparation and planning, the sight of
Claudia walking alone, and I had apparently negated all of
This was also more than a little curious. Claudia had
taken weeks to learn to make eye contact, and was not at the
time even close to reliably throwing her ball back to her
trainers. Yet I had pushed the walking just once and it
disappeared. How could one who learned so slowly suddenly
learn so fast? How could Claudia be so insensitive to some
things in her environment and so sensitive to others? And
why did her sensitivities seem to work against us? I did
not know the answers then, nor do I now.
We did know, however, that the last time she had walked
I was holding a cup of juice and was moving away from her.
We tried again, but this time I did not hold the cup. We
moved Claudia into the kitchen, I showed her the cup, placed
it at the edge of a counter, and moved away. Georgianne
lifted her as before, walked her tov;ard the counter, and let
go. Claudia covered the remaining three feet on her own and
(with Georgianne 's help) collected her well-deserved juice.
We continued in the kitchen for a week, ten to twenty
trials per day. We recorded the number of independent steps
per trial and gradually increased the distance we required
Claudia to walk by herself (Figure 11, phase A). We ran out
of room when she reached eight steps per trial and moved back
into the hall. We set up two small tables and substituted
spoonfuls of blend for the juice. Georgianne left Claudia
sitting at one table and placed the spoon on the other table.
She returned to Claudia and helped her up, but it was no
longer necessary to start walking with her; Claudia was able
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to begin each trial from a standing, stationary position.
Claudia walked back and forth, receiving the blend and a
brief rest at each table. We increased the distance day by
day until she traversed the entire hall, seventy of her
small steps (Figure 11, phase B) .
At each end of the hall was a short passageway leading
to the living wing doors. V7e moved the tables into these
passageways, out of Claudia's sight. She was able to turn
the corners and find her blend. During these sessions she
never stopped and sat down before reaching the goal and her
balance, while still not the best, improved.
While we were conducting these formal walking sessions,
we also encouraged Claudia's trainers to give her extra,
non-food-rewarded practice. The practice consisted of "gradu-
ated guidance" (Foxx & Azrin, 1973; Sundel & Sundel, 1975),
having Claudia walk with as little assistance as possible.
For example, after a meal, Claudia's trainer might walk her
from the relaxation chair to the lounge, holding her wrists
firmly at first, easing the pressure as she walked, and finally
letting go. We counted her attempts to sit down during these
short walks and discovered we were having no success (Figure 12)
Although she attempted to sit dovm less frequently than she
did before we began training, the rate showed no further
decrease as training progressed. We also realized that we
were possibly working against ourselves by requiring her to
v/alk without assistance in some situations while helping her
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We abandoned the graduated guidance program and required
her to walk short distances in the cottages by herself.
When she sat down, which she did frequently, we helped her
up but did not assist her in the walking. It was back-
breaking work and occasionally took twenty minutes to cover
the short distance from lobby to living wing. We didn't mind,
for she was walking alone.
Although we had expanded Claudia's training into many
areas, our primary concern remiained the rumination. We moni-
tored its frequency constantly as we added new training
programs and it did not increase.
We calculated the rate based upon the amount of time
Claudia spent with us, initially about ten hours per day.
Several months into her training, I became curious to know
how she fared when we were not present, from 7:00 p.m. until
bedtime, about nine or ten o'clock. The cottage parents
told m.e she was ruminating, though not nearly as often as
she had previously. I stayed late one night to find out.
As the other trainers left for the evening, I handed my
stopwatch to Betty, one of the cottage parents. I instructed
her to start the watch as soon as she heard me close and lock
the door, and to turn it off the first time Claudia ruminated.
She was then to bang on the plexiglass window in the door,
signalling me to return. I left the living wing and had not
yet seated myself in the office when Betty signaled. I
returned to the wing and read the stopwatch, seven seconds.
I had the washbottle of lemon juice in my pocket but did
not remove it. Claudia and I stared at one another for a
short time. I did not say or do anything as she did not
ruminate again. I reset the watch, gave it back to Betty,
and exited. I only walked far enough to be clear of the
plexiglass window, knowing that I ' d be wasting time to walk
further. I was correct; the latency to ruminate was five
seconds. This time, I had quite a bit to say to Claudia. It
didn't bother me that she couldn't discriminate her own name,
let alone the content of my lecture about behavior management
skills. It seemed as good a way as any to pass the time
and see if she would ruminate in my presence. She did not,
of course, and fifteen minutes later, Betty and I tried again.
Each of the next three trials registered less than 15 seconds
It is well-known that individuals in programs such as
Claudia's-- programs designed to eliminate undesirable be-
havior — quickly learn when it is and is not "safe" to emit
the target behavior (Lovaas & Simmons, 1969; Rollings, Bau-
meister, & Baumeister, 1977). Claudia's performance that
night indicated that she had learned. I went home to ponder
the problems of after-hours rumination.
Several days af ter>7ard^ I stayed late again to v7ork in
the office. It was not hard to avoid the living wing and a
rediscovery of Claudia's unmcnitored rumination. However, I
did not stop working until after 10:00 p.m. and I couldn't
resist looking in to see our kids, so noisy and unmanageable
by day, sleeping peacefully. Some clients slept, others
were awake but relaxed, and Claudia lay comfortably curled
1 considered the alternatives. We could not extend our
training schedule, and Claudia was already receiving more of
our time than was any other client. Neither did I want to
ask the cottage parents to intervene in the rumination. Two
of them were responsible for showering the girls and putting
them to bed, and I couldn't expect them to monitor and inter-
vene consistently. In addition, the Florida behavior manage-
ment guidelines, while unclear on the point, seemed to forbid
such intervention by untrained personnel.
T therefore took no action and hoped for the best. The
decision eventually proved correct. The nighttime ruminating
gradually decreased, as verified by the cottage parents'
reports and our periodic monitoring.
The first week in April, just before we began Claudia's
walking program., I happened upon a fascinating occurrence in
the boys' wing. One of the cottage parents was preparing to
mop the floor after lunch when a client distracted her. As
she tended to the boy, another client spied the open, unguarded
closet. He rushed over, reached in, and removed an open bot-
tle of detergent, which he began drinking with gusto. Several
of us reached him simultaneously and grabbed the bottle
before he had consumed very much. No harm had been done and
he laughed gleefully at our angry gestures and admonishments.
Here was I, convinced that the sour, concentrated lemon
juice was controlling Claudia's rumination. The detergent
certainly couldn't taste much better, but I had just seen a
client consume it with apparent relish. The client was known
for his pranks and he invariably laughed at our scoldings;
the attention we paid him quite likely overrode the taste of
the detergent. Perhaps it was not the lemon juice but some
other more powerful aspect of our procedure that controlled
1 had a chance to find out the day we began Claudia's
walking sessions. Georgianne was struggling with Claudia in
the ill-fated assisted v/alking program. I approached with
the wash bottle of lemon juice, held it up, and sweetly
offered it to Claudia. The struggling ceased and she con-
tinued walking; Georgianne did not let go, however, remember-
ing our experience in the hall earlier that day. When Claudia
reached me, I gently squeezed a squirt of the lemon juice into
her mouth, caressed her hair, and told her what a good girl
she was. She did not flinch or jerk away as she always did
when we swooped down on her after a rumination. We sat her
down and I induced her to make eye contact repeatedly in
return for squirts of lemon juice delivered in this gentle
The results were not surprising. Researchers in the
laboratory and in teaching situations have demonstrated that
the events usually used to decrease bahavioir rates can also —
when programmed differently-- serve to reinforce behavior
(Kelleher & Morse,' 1968; Morse & Kelleher, 1970; Plumrier,
Baer, & LeBlanc, 1977; Solnick, Rincover, & Peterson, 1977).
In hindsight, I realize that I could have been more
thorough. For example, I could have replaced the lemon
juice with fruit juice and continued with the wash bottle
procedure, observing the effect upon rumination frequency.
The simple demonstration with the lemon juice, however, con-
vinced me to alter our intervention strategy. I reasoned
that the manner of delivery was the relevant aspect of the
procedure, an excited, rapid jab with the wash bottle versus
a gentle slow squeeze. The amount and kind of juice were
identical but the results markedly different.
We disposed of the wash bottle. With the new training
programs it was a nuisance to carry and besides, it leaked.
We used our hands instead, holding her cheeks between thumb
and third finger, pointing at her tongue with the index
finger. We administered this consequence as we had the lemon
juice, quickly and sternly.
For several days, the rumination frequency rose slightly
but remained v/ell within the range displayed since training
began (Figure 13, phase I). It returned thereafter to its
usual low level and we continued without the lemon juice.
Reversal and Return to Intervention
By June, there was still no change in the rumination rate,
and we thought that we had decreased it as much as possible.
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It therefore seemed a likely time to abandon the cheek-hold
procedure. We agreed to ignore the rumination and continue
all other aspects of Claudia's training. Not wishing to
inadvertently reinforce the rumination, we planned to dis-
continue for several minutes any session in progress when a
The ruminating did not increase during the first two
days (Figure 13, phase J). On the third day, however,
Claudia averaged one rumination per twenty minutes, a rate
equalled or exceeded only in the first two days of the ori-
ginal intervention. In the following week, the rate dropped,
climbed, dropped, and climbed again. Overall, it was slightly
but noticeably higher than during intervention. We knew
that this outcome was likely. We had not decreased the ru-
mination rate to zero and Claudia had therefore immediately
contacted the procedural change — she ruminated without con-
sequence in the presence of her trainers. We were not alarmed,
however. Research had shown that response-reduction proce-
dures could be eliminated, then reinstated with no loss in
effectiveness (Azrin & Holz, 1966). While we did not worry,
neither were we willing to wait. We well remembered Claudia's
appearance four months earlier. We reins tituted the cheek-
hold procedure and left it permianently in place (phase K) .
The rumination frequency gradually declined. In Novem-
ber, 1977, eleven months after we had resumed holding Claudia's
cheeks', there w^ere more days during which we saw no rumination
than there were days on which rumination occurred. By January,
19 78, several weeks would pass between ruminations.
In the summer of 1978, milk was briefly reinstituted in
Claudia's diet; it had been removed at the same tim.e as v/as
Sustacal. The rumination frequency rose slightly but per-
ceptibly (phase L) ; so milk was permanently removed from her
diet (phase M) .
As the likelihood of rumination decreased, we gradually
reduced the amount of Claudia's training time. We were even-
tually able to safely return her to the cottage living wing
within one to one and a half hours after each meal. Whenever
we felt she was ready for a decrease in training time, we
spent several v/eeks monitoring her in the living wing. We
would return her to the day room and leave, then quietly
enter through a side door and station ourselves out of sight.
We observed no rumination during these periods.
Although the ruminations were few and far between, we
never abandoned the cheek-hold procedure. There was simiply
no reason to do so. The procedure was all but unused any^^ay,
since there v/ere so few ruminations. However, when a rumina-
tion did occur, we felt it best to deliver the consequences
to keep the rate as near zero as possible.
When the rumination had almost vanished, hiring new
trainers presented a problem. Our original trainers and those
hired while Claudia was still ruminating daily understood the
importance of the rumination procedure and had many opportuni-
ties to observe the response. Trainers hired later, however,
operated under a handicap. They rarely saw Claudia ruminate
and thus did not know what they were looking for. They also
had difficulty understanding why members of the original
staff became upset if a rumination occurred and the conse-
quences were not immediately delivered. How could they
understand? They had not known the other Claudia.
In the spring of 19 76, we took our clients to a picnic
at some lakeside property owned by Sunland. I brought along
a camera to record this first of many outings we enjoyed
over the next several years. When the pictures were developed
we realized that we had not been keeping the most important
records of all. These children had changed. Photographic
documentation immediately became an integral component of
the STARS Program. For som.e of the clients, like Claudia, .
the documentation came too late. I recorded on film many of
her accomplishments in motor and self-care skills. But
missing was the most obvious change of all, that caused by
the reduction in rumination.
Our new trainers did not know Claudia as she was before
and we had nothing to show them save a blurry snapshot from
her cottage records. Our charts precisely documented Claudia's
progress but they did not reflect her transformation from a
pale, wasted figure on the cottage floor to a healthy girl
capable of learning many new things.
Advanced Ambulation Skills
When Claudia was able to walk the length of the cottage
hall, we eagerly moved the session outdoors. A long, straight
sidewalk runs from the street to Lilac's, front porch. It was
ideal for increasing the distance Claudia was required to
walk on each trial. The sidewalk is level and was therefore
a good place to teach her to walk on surfaces other than
smooth tile. There were no bumps and slopes that her poor
balance could not accomodate.
We set up two small vinyl chairs not quite thirty feet
apart. This was less distance than we required Claudia to
walk indoors but seemed adequate in view of the radical
change in environment. We used a procedure similar to that
employed for indoor walking. We sat Claudia in one chair
and put a spoonful of blend or her regular meal in the
opposite chair, helped her to a standing position, and let
her go. When she arrived at the other chair we simultaneously
gave her the food and helped her sit down. After a brief
rest, she returned to the first chair in the same manner. She
made ten to fifteen one-way trips prior to each meal.
Claudia performed well for the first three days, then
caught a twenty- four hour virus. When she regained her
health, there was trouble. There was a crack in the sidev/alk
about twenty-three feet from the front porch and when she
reached the crack she sat down. Although the crack was more
prominent than the small spaces between successive blocks,
the sidewalk had not buckled and thus presented no physical
barrier. We stood her up and held her V7rists as she crossed,
walking her back and forth over it. Still she failed to
cross the crack without assistance; so we moved the other
chair directly over it. Over several days we inched the chair
back until the crack was directly under its front legs. We
continued backing up the chair and the problem did not re-
appear, even when Claudia had to cross the crack entirely
to reach the opposite chair. We did, however, sporadically
see similar behavior throughout her training. A crack, a
parking stripe, a change in sidewalk color, and the like
occasionally stopped her. A gentle push and she crossed;
stopping did not interfere significantly with her progress.
Having solved the crack dilemma, we moved the chairs
apart at the rate of about one foot per week until we reached
forty-seven feet, the full length of the sidewalk. Unlike
her behavior while walking indoors, she did stop and sit
down occaionally before reaching the chair. In these cir-
cumstances, we stood her up, made her walk back to the chair
from which she had departed and start again. This did not
occur often and was of no major concern.
During the between-chairs walking sessions, her step
size increased to about one foot per step and her rate was
stable at just over a hundred steps per minute. The rate
remained constant — on level surfaces — throughout her train-
ing, while her step size increased to one foot, five inches.
Auxiliary Skills I: Into and Out of Chairs
Soon after we began the betv/een-chairs v;^alking program,
it occurred to us that teaching her to walk was not sufficient.
If Claudia was to learn to walk independently, she would need
a variety of auxiliary skills, such as standing up, sitting
down, climbing stairs, and walking over rough terrain. We
therefore designed a series of programs mostly composed of
the popular technique of "shaping" and "fading," guided
always by Claudia's charted performance. We built each
behavior slowly and insured that Claudia could employ the
skill in a variety of settings.
If we expected her to use her new walking skill, we had
to teach her to initiate it. Consequently, our first new
programs were designed to teach her to get into and out of
chairs and to get up from the floor, where she spent a
considerable amount of time.
We had been giving Claudia as little help as possible
getting out of her chair during the early stages of the
be tv/e en- chairs walking program, and she was almost able to
accomplish the task on her own. Once out of the chair,
however, she had to walk quite a distance for her food and
we reasoned that if we placed the food closer to the chair
she might stand up without assistance. At one end of the
cottage hall stood a clothes dryer and an ice machine. We
placed her chair one and a half feet in front of the ice
machine and set the spoon on top of it. Arms outstretched,
she rocked forward several times, finally gaining enough
momentum to stand and brace herself against the ice machine,
whereupon she received the food. We continued the procedure
for two weeks, timing each entire session of about five
minutes and counting the number of times she successfully
got to her feet (Figure 14, phase A). She quickly reached a
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rate of about five per minute, the maximum she could obtain
accounting for the time spent receiving and chewing the food.
We subsequently moved the chair further from the ice machine,
and when we ran out of room in the hall, we' moved the ses-
sion to the back porch and placed the spoon on the relaxa-
tion chair (phases B through F). On the porch, she was
walking fourteen feet from chair to spoon.
We increased the distance in this fashion for two
reasons. First, she was initially barely able to rock her-
self out of the chair, and having gained her feet, her
balance was not good. During the first phase of training she
could catch herself on the ice machine. When her balance
improved, we moved the chair yet further, and standing and
walking became a smoothly executed movement.
The second reason for moving the chair back was to
insure that she could execute the standing up motion without
immediate reinforcement. Her progress was reflected in the
between-chairs walking program, in which her trainers no
longer had to help her out of the chair. Faced with the ever
increasing distance between the chairs, she occasionally
balked. However, a few tugs on her sleeve sufficed to get
Having taught Claudia to get out of the chair without
assistance, we approached the problem of getting her into the
chair. We began on the back porch., with Claudia in the chair
facing the guardrail, about one and a half feet away from it.
We had her stand up and grasp the rail, then lower herself
into the chair v/hile letting go (phase G) . We counted and
timed each behavior as before. This was fine, except that we
had merely succeeded in replacing ourselves with the rail;
Claudia still needed assistance in getting into the chair.
We planned to move the chair back gradually and eliminate the
rail, as we had eliminated the ice machine when teaching her
to get out of the chair. When we considered the motion re-
quired to seat oneself, we realized the folly of our scheme.
Unless one is very tired or otherwise indisposed, one gener-
ally approaches a chair from the front and spins about,
simultaneously lowering oneself onto the seat. Such a com-
plex response, or even a chain of simpler responses with the
turning and lowering trained separately, was beyond either
Claudia's capability or our teaching skills.
We elected instead to teach Claudia to use the back of
the chair for support. We moved the program back into the
hall. We placed Claudia in the chair, seated parallel to
the wall, about one foot away from it. The trainer assisted
her to stand up and put one hand on the wall, placing the
other on the chair's backrest. From there, she could lower
herself into it (phase H) . When she was able to execute the
motion without her trainer's help, we moved the chair three
feet further from the wall so that Claudia had to walk to it
and seat herself using the backrest and the seat of the chair
for support (phase I) . ' This manner of sitting down proved
successful. Without specific training she applied the process
to any chairs, couches, and benches she encountered.
In the process of teaching her to sit down, however,
we learned another lesson of profound retardation: conduct
each training session with complete regard for all other
training in progress. In our eagerness and impatience to
teach Claudia to get into the chair v/e had assisted her in
getting out. We succeeded in speeding up the into-chair
training sessions, but she would not get up on her ov/n during
the between-chairs walking program. We temporarily had to
reinstate the out-of-chair procedure. During the retraining,
we patiently allowed her to seat herself.
Auxiliary Skills II: Standing Up from the Floor
There were only a few chairs in the cottage day room,
and at our insistence, a bench had been installed. These
were usually occupied by the higher-level clients, leaving
the floor to the lower-functioning and non-ambulatory clients,
Since we usually found Claudia on the floor, it was impera-
tive to teach her to get up and start walking on her own.
We began by offering her our hands. We did not pull
her; we merely extended our hands and let her pull up, where-
upon she received the spoonful of food without which we could
induce her to do absolutely nothing. We then reseated her
and repeated the process for about two minutes. She pulled
herself up in this fashion slightly less than twice per
minute (Figure 15, phase A), and we wondered if we might have
more success by substituting inanimate objects for ourselves.
We used the dryer in the hall, placing Claudia directly
in front of it and the spoon on top of it. Rocking forward.
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she placed her hands, on top of the dryer and pulled herself
to a standing position without assistance from the trainer.
We timed the entire session as we had before, counting the
number of times she stood up. She initially stood up twice
per minute and increased the frequency to seven per minute in
three and a half weeks (phase B) .
Although Claudia proficiently used the dryer to stand up,
we wanted to insure that she could sim.ilarly use any available
object. A behavior learned in one setting will frequently
fail to occur in other settings without explicit programming
(Rekers & Lovaas, 19 74; Stokes, Baer, & Jackson, 19 74; Koegal
& Rincover, 1977) . We therefore conducted the session in a
variety of locations, moving from the dryer to the ice machine,
clothes chest, and various walls and ledges (phases C, D, E, F)
As we had done when teaching her to get out of her chair,
we required her to stand and walk increasing distances before
she received her food. During the latter portion of this
program, her trainers would no longer help her up when they
arrived for her mealtime sessions, requiring her instead to
employ her new skill.
During the final two weeks of the program, we noticed
that she was barely using the walls and ledges for assistance.
We therefore added a new program, requiring her to stand
entirely unassisted. She used the same basic strategy that
she had developed to get out of the chair, rocking forward
with arms outstretched until the momentum brought her to her
feet. During the first phase, we delivered the food as soon
as she was standing [Figure 16, phase A). For the next nine
weeks, we conducted the session almost daily, requiring her
to walk three or four steps for food (phase B) . Thereafter,
we maintained the session sporadically eventually delivering
the food on a VR2 , then VR3 schedule (i.e., food on an aver-
age of two, then three trials; phases C, D) , When we elimi-
nated the program altogether, she was able to stand up about
ten times per minute, for three minutes at a time. Although
one might have expected the variable food-delivery schedule
to maintain a higher response rate than that maintained by a
continuous schedule (Reynolds, 1968), such was not the case
in Claudia's stand-up program. She was probably not physically
capable of executing the performance faster than ten times
per minute. Neither was I: Matching her stand-up for stand-
up, I was embarrassed to discover that I looked considerably
worse for wear than did she, and I was not simultaneously
trying to chew and swallow.
The Daily Constitutional, Part I
About a month after we began the between-chairs walking
program, we realized that while Claudia was progressing
nicely, she was not getting very much practice. Most of the
walking was in a straight line, met by food at each stop.
The remainder of her walking occurred in the cottage and
covered very short distances. We had taught her the skills
necessary for more extensive v;alking, but she did not use
them. If her walking was ever to amount to anything, we
clearly had to expand her training.
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The afternoon was the best time for such., an undertaking,
since she was with Julia for a large portion' of the morning,
and we went home shortly after supper. Our training building
was located several hundred yards from the cottage and seemed
a likely target. It was August, and th.e air conditioned
building offered a break from the vicious heat before the
return to the cottage. The building was also stocked with
enough balls to amuse Claudia for hours. We knew that Claudia
could not make the entire trip on her own, and v/e therefore
abandoned our policy of providing no assistance. By this
time, she was walking fairly proficiently inside the cottage,
and we gambled that providing assistance during her walk
would not affect her indoor program. We gambled correctly, ,
but it was small consolation for Georgianne, who spent the
hottest summer of her life between Lilac and the STARS build-
ing. Everyday she and Claudia left from Lilac's backdoor and
followed driveways, streets, and sidewalks to arrive exhausted
at our building (Figure 17) .
Some parts of the route were rougher than others, and in
these Georgianne held Claudia's wrist firmly. In the smoother
sections, Georgianne walked close behind Claudia, and when
she began to sit down, Georgianne held both her arms straight
up to prevent sitting. Georgianne would then do her best to
start Claudia walking again, supporting Claudia by the arm.pits
and moving her for^vard, ' If repeated attempts to initiate
walking failed, Georgianne took Claudia's wrist and assisted
her until Claudia was walking smoothly again, ready for another
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try at independent walking. They both rested every few hundred
feet. Georgianne counted the number of independent steps and
attempts to sit down on the way to the STARS building (Figure 18,
phase A). A one-way trip was enough, perhaps too much, and
we returned Claudia to the cottage by assisting her throughout
A one-way walk required about 1300 of Claudia's small
steps, and during the first two weeks the only change was in
the condition of Georgianne' s back. Georgianne therefore
devised a new, less taxing procedure, placing her knee under
Claudia's seat to prevent sit-downs (phase B) . Both her back
and Claudia's walking improved. Claudia averaged nearly 350
independent steps per journey, more than twice as many as
In September, we added several features to the program,
and the sitting improved further. Claudia's parents bought
her a new set of tennis shoes to replace the worn-out,
heavier saddle shoes in which she had learned to walk.
Georgianne also brought a ball along for the walk which she
placed 200 feet ahead of Claudia for use during rest breaks.
The most significant change was probably the new route we
chose, leaving from Lilac's front door and following sidewalks
most of the way. The number of independent steps jumped to
over a thousand, and within five weeks Claudia could walk
most of the route on her own (phase C). The number of attempts
to sit down changed little over the course of the program.
This was further evidence of Claudia's progress, since there
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was one attempt for eacii twenty-five independent steps when
she began and one in 250 in the latter portion of the program.
The Daily Constitutional, P art II
Georgianne left the STARS Program in late September, and
I continued the after-lunch walking sessions while inter-
viewing applicants for the vacant position. I hired Cindy,
who tolerated the walking sessions for about a month before
pointing out a problem. Hadn't I noticed that Claudia's
attempts to sit down no longer appeared when she encountered
rough spots enroute to our training building? Rather,
Claudia would turn to walk in a different direction; we would
re-orient her toward our building; and only then would she
It was true; I had fallen into a rut. In my desire to
see Claudia walk to the STARS building without any assistance,
I had not considered alternatives to the daily ritual.
we let Claudia choose the direction of her daily con-
stitutional. AS long as she walked for about half an hour
each day, we didn't care where the walks occurred. In fact,
the new policy had many advantages, Claudia learned to walk
on grass, dirt, bumpy streets, and the like, without explicit
programming. Her trainers were pleased, as they had an op-
portunity to explore other parts of the campus. We expanded
the session to included short strolls ^fter breakfast and
Claudia became increasingly attentive to the environment.
She began looking aroan.d her, at people, moving vehicles, and
objects and buildings, Her favorites were the small, manually
operated merry-go-rounds that were located in almost every
playground. She would spot one of these from several hundred
feet away and walk over. We could spin her until we were
exhausted; the faster we pushed, the more she laughed. In
inclement weather, she frequently walked inside the campus
hospital, where she was a welcome visitor. She rode the
elevators and walked endlessly up and down the halls, ex-
ploring the wards and lounges. Many of the staff had known
her before, and their exclamations at the change in her made
us redouble our efforts.
We 'tried a number of recordkeeping formats to monitor
her progress, and after several months settled on a general
measure of assistance. Her trainers counted as an assist
any instance in which they either had to catch her to pre-
vent her from falling, or give her a small push when she
balked at something in her path. The assists gradually de-
creased from about one every two minutes to about one in
twenty minutes, or several per walk (Figure 19). I purchased
a pedometer to obtain a measure of distance, but the records
were unreliable due to her swaying gait. We eventually merely
recorded the amount of time she spent walking each day and
kept a log of the places she went. These were sufficient
to keep track of the program,
Claudia's hands and arms also provided us with an informal
measure of her improvement. During the early stages of walk-
ing, she always kept her hands up and out to her sides, arm.s
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flexed at the elbow. Over the months, she gradually lowered
her arms. Eventually, she walked with them hanging loosely
at her sides, raising them only when crossing rough terrain.
In the early part of the program, Julia continued to
take Claudia out in the wheelchair. We did not object.
Keeping Claudia on the move was strenuous work, and Julia
was elderly. However, as the walking improved, the other
foster grandparents chided Julia, who eventually succumbed to
peer pressure and abandoned the wheelchair. This pleased us
immensely, since V7e knew that we would eventually have less
time to spend with Claudia. .We now had a guarantee that the
walking would be maintained. Further, we did not have to
push for the change; the goad had come from others who had
noticed Claudia's progress.
Auxiliary Skills III: Climbing Stairs
During the last few weeks of Claudia's walks to our
training building, she seemed sure-footed enough to learn to
walk up and' down stairs. Because of the operation, her rigid
ankles would probably never allow her to scale steps without
support. However, teaching her to use a support rail or
bannister seemed a reasonable goal.
The front steps of Lilac were a likely beginning. There
were only three shallow steps, each three and three-quarter
inches high, leading to the porch v/hich was surrounded by a
steel rail. The rail terminated at each side of the top step,
and, although there was no bannister, Claudia could easily
reach the rail from the foot of the steps.
We had previously been assisting Claudia whenever she
encountered steps, holding both her hands tightly and bracing
her against us. We had noticed that it was easier to help
her up the steps than down, so we began by teaching her to
Since we had always assisted her ourselves, our first
task was to teach her to grasp the rail. We started her on
the sidewalk about five feet from the bottom step, had her
walk to the foot of the steps, lean forward and grasp the
rail, whereupon she received the familiar spoonful of food.
She learned to grasp the rail with both hands within a week,
and we began working on the actual step-climbing.
We continued the procedure as before, giving her a five-
foot start, but now we walked ahead . of her and waited on the
top step. We counted the number of stairs she scaled, start-
ing the timing on each trial when she began walking and turn-
ing off the watch when she had both feet on the top step. She
learned the skill quickly, increasing from the original nine
stairs per minute to fifteen stairs within several weeks
(Figure 20, phase A). We worked next on walking down, giving
her food at top and bottom, but counting and timing only while
she descended (phase B) . We then briefly returned to moni-
toring only while she walked up (phase C) , to be sure she
had not lost her former speed in this component. We completed
the program by recording the rate at which she both ascended
and descended the stairs (phase D) ,
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Claudia was ready for a new set of steps, but none were
to be found. Due to her limited walking, there were no other
stairs with support rails v/ithin easy access from Lilac, so
the program was temporarily stalled. Her trainers worked
with her on stairs they encountered during her after-meal
strolls, but we did not wish to feed her at these times, and
without food, getting her to climb was usually a struggle.
We ordered a set of wooden playground stairs, with five six-
inch steps and support rails. While we awaited delivery, we
continued to practice on the front steps of Lilac.
When the new set of steps arrived, Claudia both ascended
and descended them as well as she could the cottage's more
shallow front steps, probably because of the bannister. She
received her food after completing all five steps. There was,
however, a new problem. When walking up, Claudia frequently
took two steps at a time, and in doing so occasionally tipped
backward. To eliminate the behavior, we blocked with our feet
each attempt to take two steps, pushing her feet back to the
appropriate step. The attempts slowly decreased as she learned
to climb the steps more rapidly, beginning at about twelve
stairs per minute and increasing to over twenty-five. We began
using the left side (facing) bannister and later switched to
the right side (Figure 21, phases A, B) .
Claudia descended the steps only slightly more slowly
than she ascended them. She did not attempt more than one step
at a time, but at first required her trainers' assistance to
keep her hands on the rail and to keep moving (Figure 22,
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phase A) . She soon needed no assistance, and we proceeded
in the same manner as in the up- steps component, using the
left, then right rails (phases B, C) .
By the time Claudia reached what was apparently her top
speed on the playground steps, her walking speed and balance
were sufficient to permit us to find new stairs for practice.
The hospital had several outdoor staircases with rails, and
we made use of these, practicing on each set until she
climbed up at the rate of at least twenty steps per minute
and down at at least fifteen.
Her proficiency was reflected in her after-m.eal walks.
We no longer had to struggle with her to climb stairs, even
when no food was in the offing. The skill opened new avenues
of exploration for Claudia and made our time with her far
Auxiliary Skills IV: Crossing Obstacles
Although Claudia was learning to walk over many surfaces,
any transition (sidewalk to grass, etc.) or obstacle higher
than about one inch caused her to stumble or to stop walking
and hold out her hand to her trainers. She was improving,
but we sought to speed up the process by carefully programming
a series of obstacles of known dimensions. As she became
proficient at crossing each, we added to it, increasing the
difficulty only slightly. We ordered a set of boards which
arrived in August, 19 77, at the same tim.e as the playground
We conducted the session in much the same manner as we
had the between-chairs walking, placing two chairs eight
feet apart on the sidewalk in front of Lilac. The first
obstacle was a single board, one and a half inches high and
three and a half inches wide, centered on the walk between
the chairs. She walked from chair to chair ten to fifteen
times, receiving her food and a brief rest at each stop. We
counted the number of times she crossed the boards, operating
the stopwatch between the time she left one chair and ar-
rived at the other. We counted an assist if we had to push
her when she balked, or if she bent over and used her hands
to help herself clear the board. She learned to cross the
board quickly (Figure 23, phase A) , and we moved the chairs
eleven feet apart, placing another board parallel to the first
and centering both between the chairs. Again she performed
well (phase B) .
We increased the height of one of the boards to three
inches, leaving the other at one and a half inches. The
number of assists rose sharply, but declined within a week
(phase C) . We continued the sequence by increasing the height
of the second board to three inches, but Claudia apparently
disagreed with our logic. The number of assists, which began
at one in every ten boards, increased to an assist for every
other board (phase D) , I briefly tried replacing the second
board with one only one and a half inches high, but v/ithin
several trials, I could see the problem had not disappeared.
I removed the smaller board entirely and centered the single, ,
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three inch board between the chairs. We retained this
configuration for five weeks (phase E) , then successfully
added the second, one and a half inch board (phase F) .
I was unwilling to increase the height of the second
board to three inches and risk failure a second time. In-
stead, I changed the obstacle from a board to a small plat-
form, two and a quarter inches high and one and a half inches
wide. This was considerably more difficult than the previous
task, requiring Claudia to step up on the platform, gain her
balance, and then step down. I therefore changed our policy
of providing no assistance except a gentle push. Each time
she approached the board, I placed my thumb and index finger
under her right wrist to help her balance. I did not want
to hold her hand, fearing that it would be difficult to
gradually reduce the amount of assistance. She rapidly
learned to get up on the platform, and stepping dovm was never
a problem. I assisted her in this manner on almost every at-
tempt, although several times she was up on the platform
before I was ready for her (phase G) .
Fortunately for Claudia, I had to leave for several days,
and Kris, a new trainer, conducted her sessions. Through a
miscommunication, Kris thought that she was supposed to assist
Claudia only when Claudia balked at the platform. This, in
fact, was all the help that Claudia needed, and we continued
to train under the new policy (phase H) , ' We successfully
raised the platform to three inches (phase I) , then four and
a quarter inches (phase J) ,
Claudia's walking skills had progressed markedly. She
balked at fewer obstacles and crossed rough terrain more
easily. The improvement was most obvious when she encountered
low curbs. Prior to her training with the platform, she had
never surmounted a curb on her own. When the platform height
reached three inches, we could induce her to scale the curb
with a bit of gentle pushing, and when the platform was raised
to four and a quarter inches, low curbs were no longer a
Claudia could truly walk by herself.
The Campus Cafeteria
Marsha left the STARS Program in mid-November, 1976.
During her last week with us, she instituted a change that
affected the entire program. We had just eliminated Claudia's
walk from Lilac to our building. If Claudia could now walk
where she pleased, Marsha reasoned, why couldn't she walk to
the campus cafeteria? It was located less than two hundred
yards from Lilac. As much as Claudia enjoyed eating, it
should not be difficult to induce her to make the short trek.
Her feeding skills were hardly polished, but she could handle
a spoon, and the relaxation chair was adding nothing to the
The change was miade and Marsha departed for her new job.
Cindy, Mardi , who replaced Marsha, and I were left to continue
the program. Once again, the unexpected happened. Claudia
might walk well after meals, when she chose the direction, .
but going to the cafeteria was another matter. Once there,
she seemed to enjoy it, making her excited noises and gestures
smiling and laughing at all the activity. But we had to
struggle to get her there. Perhaps it was because she had
always eaten at the cottage and then gone for her w-alk; we
were attempting to leave Lilac before she had eaten. Most of
her struggling and attempts to sit down occurred on Lilac's
front sidewalk. Once past the walk and away from Lilac, the
going was easier.
We considered taking food or juice to feed her periodi-
cally along the way, but decided against it. She had been
walking considerably further without food for several months
and adding food now would be a step backward. This was
probably an incorrect decision. We assumed that she could
make what was for her a relatively long journey because there
was food at the end of it. How could we expect her to make
the whole journey right from the start? We had worked with
her for almost a year, painstakingly building each skill a
little bit at a time. Now we were trying to effect a major
change with no preparation ^t all. Claudia's trainers some-
times learned as slowly as did she. Nevertheless, we kept
trying, using the same procedure as we had during Claudia's
walks to our building, and finally succeeded. After several
months, Claudia walked the entire distance without help or
urging from us. Eventually she laughed and walked at her
maximum speed, a hundred and forty feet per minute, en route
to eat, coming as close as she ever did to actual running.
Meanwhile, the rest of the STARS Program followed our
lead. In tim.e , most clients who learned basic feeding skills
began eating at the cafeteria. It was a pleasant and re-
warding change from the confines of Lilac for clients and
Eating Skills in the Cafeteria
During the first six months in the cafeteria, we did
nothing more than continue Claudia's scooping program. We
were assisting her with every scoop when we arrived and later
assisted her only when necessary (Figure 9, pp. 63-66). As
her walking was still rather limited, we did not attempt to
have her go through the food serving line. Rather, we seated
her, brought her her food, and returned her tray to the dis-
posal window after the meal.
By the end of June, 1977, Claudia could use her spoon
with little assistance. We decided that it was time for her
to learn to use a fork. Forks had not been available at Lilac,
but they were at the cafeteria. Many of the higher level
clients at the cafeteria could not use forks, but the pro-
gram seemed worthwhile since many items, such as salad, were
more easily stabbed than scooped.
During each meal we allowed Claudia to eat most of her
food with her spoon, setting aside any chunks that would be
easy to stab with a fork. Vie then placed the fork in her
hand and assisted her in stabbing the first few chunks.
Thereafter, we gave her an opportunity to stab each piece.
If she failed after several attempts, or if she tried to
scoop' with the fork/ we assisted her in stabbing that chunk.
The strategy did not work. She was not putting any force into
her stabs and rarely succeeded in spearing her food (Figure 24)
We tried assisting her with every chunk for the next two
months, but we observed no increase in force. She was no
closer to success than she had been when we started the pro-
gram, so we terminated it. Using a fork was not vitally
important to Claudia's eating skills, but our failure to
teach her was yet another disappointment in this difficult
area of her training.
We met with considerable success, however, in teaching
Claudia to handle her cup. We had always assisted her with
this task, since if we did not, she would pick up her cup,
take a drink, and then drop the cup, whether or not liquid
remained in it. Claudia normally paused only two or three
times while drinking, giving us few opportunities to replace
the cup on the table. To increase the number of opportunities,
we placed only a sip or two of juice in the cup for each trial.
For three weeks, we allowed her to pick up the cup and drink
the juice by herself. As she brought the cup away from her
mouth, we grasped her wrist firmly and guided her hand to
place the cup upright on the table, releasing her wrist when
she had released the cup. At first we had to do all the work;
we could feel the resistance as we guided her hand. Gradually
the resistance decreased and at the same time she learned to
release the cup as soon as she had placed it on the table. We
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replaced the all-assisted procedure with one in which she was
given the opportunity on every trial to replace the cup on
the table by herself. If she dropped the cup or set it dov/n
sloppily so that it tipped over, we counted an incorrect
response, replaced the cup in her hand and assisted her to
set it down correctly. During the next two months, the
incorrect cup placements decreased from about one in every
four attempts to fewer than one in twenty (Figure 25) . We
could then safely give her the entire cup of liquid at once.
She never dropped it, but she occasionally set it down on
top of her silverware, allowing it to tip over. This hap-
pened rarely, and the mess created was well within the limits
tolerated by the campus cafeteria, where spills, dropped
trays, and other accidents were a common occurrence.
Claudia also spilled a considerable amount of liquid
while she drank. She held the cup at too sharp an angle and
frequently left it there when not swallowing, allowing the
juice to run out of her mouth and onto her bib. We never
succeeded in eliminating the spills, but the amount of
liquid spilled decreased sharply after she learned to handle
the cup. After that program was terminated, she always
lowered the cup when not actually drinking. Interestingly,
she did not replace the cup on the table during each pause,
a by-product we were afraid the program might have produced.
Rather, she often lowered the cup mom.entarily , then resumed
drinking. She was not exactly fastidious, but she could
definitely drink without our assistance.
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The Serving Line and Carrying the Tray
In late 19 77, when Claudia had been eating at the
cafeteria for about ten months, her walking skills were
advanced enough to allow us to teach her to carry her tray.
We designed two programs, one to occur in the cafeteria at
mealtime and one to take place at Lilac.
When we arrived at the cafeteria, we seated Claudia and
took a place in line. At the head of the line, we brought
Claudia over and assisted her through the entire process,
guiding her hand to take silverware, dessert and main course
dishes, and a drink. We used spoonfuls of food to induce her
to push her tray, replacing her hands on the edges and prompt-
ing her to push when necessary. At the end of the serving line
we stood behind Claudia, made sure she was grasping the tray
firmly, held the tray lightly ourselves, and guided her to .
the nearest table. After the meal, we used the same proce-
dure to guide Claudia to the disposal window. We reserved
more intensive training for extra sessions at Lilac. The
cafeteria was crowded, and we did not wish to add to the
confusion with the dropped trays, spills, and stalls we knew
would accompany the program.
The kitchen counter in Lilac, about ten feet long, was
perfectly suited to our purposes. We placed a bowl of blend
on a tray, arranged Claudia's hands on the edges, took the
spoon, and had her follow us, sliding the tray. When she
reached the end of the counter, she picked up the tray and
carried it back to the starting point, ready to begin the
next trial. We conducted. about fifteen trials per day. At
the beginning of this portion of the program, we gave her
two spoonfuls of food per trial, one about half v;ay down the
counter and one when she returned to the starting point.
After several weeks, we gave her only one spoonful at the
end of each trial. We assisted her when necessary, replacing
her hand on the tray as she pushed it or leveling the tray if
it tilted while she carried it. At the beginning of the pro-
gram, we were not always as quick as we should have been and
had to clean and mop the kitchen floor regularly. Our assists
gradually declined to one or two per session, while her rate
of trial completion (we timed only during trials) rose from
less than two per minute to approximately five per minute
(Figure 26, phase A). By the end of this training phase, we
no longer had to prompt her to push the tray in the cafe-
teria line, so we concentrated on teaching her to carry it.
Claudia now carried the tray from the end of the kitchen
counter into the hall, to the clothes dryer, about fifteen
feet away, where she received her food. Each session con-
sisted of about fifteen trials, or one-way trips. We as-
sisted her in leveling the tray whenever the bowl of blend
began to slide (phase B) . Although she rarely tilted the
tray enough to dump the blend before we could catch it, we
were not satisfied with the program. The blend bowl was too
heavy to be a sensitive, reliable indicator of tray tilt, and
we could not trust our vision because the tray jiggled con-
siderably when she walked. We solved the problem of finding
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a sensitive, mess-free, criterion by placing a steel weight
in the bottom' of a plastic cup. The cup and anchor weighed
about six ounces, enough weight to prevent the cup from top-
pling at the slightest jostle. When the cup did fall, we
righted it, adjusted the angle of the tray, and counted the
occurrence. As Claudia gained speed carrying the tray, the
cup fell less and less often (phase C) . When the cup was
falling less than once per ten carries, we replaced the steel
weight with a wood block, decreasing the total weight to
about three ounces (phase D) , then used an empty cup, which
weighed two ounces (phase E) .
In the cafeteria, we stopped "shadowing" Claudia and
holding her tray at the same time we replaced the steel weight
with the block. However, we remained only inches from her as
she carried the tray to her table, or to the disposal window
after meals. When the block was removed from the cup, we
were able to stand several feet from Claudia in the cafeteria.
She did occasionally dump the tray, but accidents of this
nature occur periodically among all but the highest- level
clients. As was also common practice among the cottages
attending the cafeteria, vie carried Claudia's juice cup for
her when it was filled to the brim: We could not reasonably
expect her to perform a task that we ourselves had trouble
We were unable to teach Claudia to go through the serving
line independently. She eventually learned to pick up silver-
ware, but never discriminated knife," .fork, and spoon. Without
our assistance, she put her hands into one of the bins and
extracted one or more of whatever happened to be in that bin,
but there the learning ceased. Progressing through the line,
she usually needed assistance to take the food dishes. The
assistance usually consisted of pushing her hands toward the
dishes. Once aimed in the right direction, she would usually
take the dish, occasionally requiring additional assistance to
place it on the tray v^ithout spilling the contents.
Watching Claudia go through the serving line and take
her tray to the table, I thought back to the time, a year and
a half earlier, that we began walking her to the cafeteria.
It had been such a struggle to make her v/alk that we had
nearly abandoned the program. How unfair to her it v/ould have
been had we done so.
Final Aspects of Training
Exploring Out the Gate
Ask a "high-level" where he or she would like to go, and
the answer is frequently "out the gate," The Sunland campus
is neither locked nor hidden behind massive walls. It is, .
however, bounded by fences, and many clients rarely leave the
premises. Going out the gate is a treat — a shopping trip or
an afternoon of bowling with a volunteer sponsor, or a group
outing to a concert or sports event. Advanced clients earn
special status by attending off-campus schools or by gaining
employment in the com.munity, and the most advanced can leave
the campus permanently to reside in a group living home.
Our clients had seemed to enjoy the first off-campus
picnic at the lake/ and field trips became an important part
of the STARS Program. Although the clients were nonverbal
and could not ask us to take them out the gate, their ex-
citement as they boarded the bus on Saturday and Sunday morn-
ings was proof enough, and several of them invariably became
sullen and cried when we returned to the campus.
The field trips were a welcom.e break in routine for both
clients and staff, and provided a chance to practice newly
learned skills in novel environments. For those of us working
with Claudia, the field trips were a way to watch her grow.
We brought a wheelchair for her on the first picnic; we had
just begun her walking program, and she took but a few inde-
pendent steps in the grass at the lake. The wheelchair was
soon unnecessary, and, with her trainers' prompting and coax-
ing and with frequent rest breaks, she was able to keep pace
with the expanding scope of STARS field trips. We attended
local events such as parades and the circus, visited parks
and other attractions, and ate at several restaurants.
During this time, the number of stimuli to which Claudia
responded increased m.arkedly. Loud noises, m.usic, brightly-
colored fast-moving objects, and large groups ■ of people
attracted her attention. She watched intently, grew excited,
laughed, and walked without prompting to explore her surround-
ings. Her love of motion, which we had discovered when riding
her in the relaxation chair, continued. Rides at carnivals
were the most exciting, but she even enjoyed the bus rides.
laughing at the sight of the bus parked at Lilac's, back door.
i\s she progressed in !ier ambulation training, she learned
to board the bus and seat herself without assistance.
In the spring of 1977, a year after the first picnic, the
STARS took an all-day trip to Disney World. It was a big
event for us and required all the skills we had taught our
clients. Watching Claudia walk through Disney World and
enjoy the attractions, I could see clearly the effects of
her intensive training. It was a fine professional reward.
Expanding the Daily Constitutional
Marsha returned to work in the STARS Program just before
the trip to Disney World. Although she had visited periodi-
cally during her absence, her new, close contact with Claudia
provided her an excellent perspective for comparison. When
she had left the program, Claudia was slowly, painfully
learning to walk to the cafeteria. Noting the improvement in
ambulation skills and, particularly during the day at Disney
World, Claudia's progress in other areas, Marsha suggested
that we begin taking Claudia off-campus more frequently.
Claudia's afternoon walking session, which originally
seemed to offer an endless supply of new environments, had be-
come somewhat confining. Claudia could walk to almost any
point on campus, limited only by time. Interspersing off-
campus trips with these walks would provide a fresh supply of
novel situations. A five-to-ten minute drive gave access to
a variety of parks, playgrounds, shopping areas, and local
events. Riding in the trainer's car was, of course, half the fun,
We maintained data regarding the off-campus trips in
the same fashion that we monitored her on-campus walking,
keeping a chart of walking time and a log of places visited.
The number of stimuli to which Claudia was exposed multiplied
During my time with her, Claudia made many changes be-
sides those described in the preceding pages. These changes
are perhaps best labeled as social behaviors or "responsive-
ness to others »" Although these changes were among her most
important and advanced accomplishments, we unfortunately did
not quantify them for a variety of reasons. As other researchers
(e.g., Harris et al. , 1964; Risley, 1968) have found, the
social behaviors emerged largely as a by-product of her train-
ing and as such were never monitored closely. We were often
unaware that a behavior was emerging or changing until the
change was so obvious that we could not have ignored it had
we tried. The lack of data deprived us of an opportunity to
study the development of the new behaviors, but we apologized
to ourselves by noting that our measurement and training ef-
forts were directed to the more immediate priorities of ru-
mination, ambulation, feeding, and the like. We did not know
why these other changes occurred but were grateful for them.
During my last year in the STARS Program, Claudia began
to laugh considerably more often and began, albeit infre-
quently, to respond to her name. On her walks she gradually
began to follow her trainers; earlier, we constantly had to
physically steer her in the desired direction.
Most notable was the change in the amount of physical
contact she had with us. Many of the trainers would gather
after meals in Lilac's lounge or outdoors to relax, monitor
the clients for self-abuse, and to give the clients extra
time out of the cottage. During these times we played with
Claudia, tousling her hair, patting her stomach, and other-
wise physically interacting with her. Claudia was originally
indifferent to these overtures, ignoring them or pushing our
hands away, preferring instead to bounce her ball. Gradually,
she began to tolerate the contact and then to seek it. If we
seated her across the lounge, she would walk over and sit
beside one of us, taking our hands in hers and placing them
on her head or face.
When we finally became aware that these social behaviors
were emerging, we undertood to teach a specific response, ,
hugging. To our discredit, we again failed to collect quan-
titative data, and thereby deprived ourselves of yet another
opportunity to study a significant aspect of Claudia's growth.
The training was simple and informal. We took advantage of
her newly acquired behaviors of approaching and touching us.
At various times while she walked, her trainer walked ahead
of her, then stopped and v/aited. She generally walked up to
the trainer and stopped. When she did so, the trainer bent
down and placed her arms in hugging position, directly around
the back. The trainer reciprocated the hug, patting her back
lightly for a few seconds, then resumed the walk. We were
quickly able to eliminate physical assistance. Within
several weeks we needed only to tug lightly at her arms or
gently nudge her elbows to initiate a hug, and even these
prompts were soon rarely necessary.
Of all Claudia's trainers, I was the slowest to recog-
nize the significance of these new behaviors. Immersed in
monitoring her progress in her regularly scheduled program.s,
I failed at first to realize that the new behaviors, parti-
cularly the hugs which we had specifically shaped, were
different than other behaviors we had trained. Conspicu-
ously absent were the usual reinforcers^ — the opportunity to
leave the cottage, riding motion, and especially food. Rather,
our physical contact with her appeared to function as the
reinf orcer .
Sitting with her in the cottage one night, I sought to
confirm this observation partially by calling upon her old,
familiar "eye contact" response. I picked her up, swung her
around several times and roughhoused her, making her laugh and
grow excited. I reseated her and told her, "Look at me,
Claudia." The unmistakable expression appeared; I hugged her
for several seconds; and she began laughing again. I stood
up and issued the command again. Once more she made "eye
contact," and I hugged her; again she laughed. I repeated the
sequence about ten times more, then attended several other
clients for about five minutes, allowing her to settle down.
I approached her again and this time I did not begin by
exciting her, rather beginning directly with the command to
look at me. "Eye contact" followed the command almost im-
mediately and continued to do so for perhaps another ten
trials, at which time I terminated my "experiment." In
retrospect, I could have obtained clearer evidence of the
reinforcing nature of the hugs by engaging in more sophis-
ticated behavioral analysis. I could have, for example,
added another set of trials in which I ignored the eye con-
tact, then performed a third set in which the hugs were
reinstated ("ABA" design) , Other manipulations would have
permitted more detailed exploration, such as isolating the
relevant aspects of the hugs.
Unfortunately, I did not pursue these avenues. The
ideas did not occur to me at the time. I was too excited by
the realization that Claudia had changed in a way that we had
not even contemplated when we first observed her on the floor
of Lilac. We had decreased the rumination and given her a
variety of basic living skills. Now, she had developed
social behaviors. They were perhaps rudimentary, but to us
and to Claudia they made a difference.
The Limits of Training
We attempted to teach Claudia many things and obviously
did not always succeed. In some cases, she learned well up
to a point, beyond which she did not advance. In other cases,
our basic or preparatory training failed, and we abandoned
altogether our efforts in those areas. There were also
akills that we never even attempted to teach her.
Whenever our training was styiriied, v/e had to ask our-
selves whether the problem was our technique or whether the
goal was beyond Claudia's capabilities. There was, of
course, rarely a definitive answer. For alm.ost every failed
strategy several alternatives were available. These we had
to weigh against her previous progress in that area, her
progress in other areas, and against considerations such as
probable expenditure of time, energy and money. When we
tried a new tactic and succeeded, we felt vindicated. When
we elected to discontinue a program, we did so with reluc-
tance. Perhaps another day or week would have made the
Review of Training Discussed Heretofore
Teaching Claudia to eat independently proved more
disappointing to us than any other area of her training. Per-
haps this was because she learned the basic skill, scooping
with a spoon, so rapidly. In comparison, her subsequent
progress seemed incredibly slow, and in some areas she never
progressed. After tv/o and a half years, we had succeeded in
that she could independently eat her entire meal and drink
her juice.' But there was also much she could not do. She
still needed a bib to collect spilled food and liquid. Al-
though she did not scoop backhanded, her forward scoops
pushed a considerable amount of food off the plate. We had
failed in teaching her to use a fork, and, based on her
loose grip of the fork and her limited maneuvering of the
spoon, we had not tried to teach her to cut the food. With
further training, she may someday eat neatly, without a bib.
But is using a fork and knife a feasible goal? At the tim.e
we tried to teach her, it was not. Perhaps the opportunity
will arise again later, when she has had several more years
of practice at eating by herself and if those v;orking with
her at that time have found a more effective teaching tech-
Claudia progressed neither as far nor as fast as we had
hoped after the first week of her scooping program. But
when we first saw her lying on the floor of Lilac, we did
not even contemplate teaching her to feed herself. Consider-
ing Claudia's initial state, her feeding programs hardly
Her progress in the cafeteria must be viewed likewise.
She could not go through the serving line by herself and,
in fact, could not wait in line for more than a minute or
two. Neither, however, could many of the other clients who
lived in higher level cottages. Again, she may yet learn
to do these things. In my training with her, she did not.
In teaching Claudia to walk, the most successful of
our training efforts, we also faced lim.its. I doubt that
she will ever run, although her speed as she approached the
cafeteria in mid-19 7 8 cast doubt upon this prediction. A
year earlier, the prediction seemed a safe one. The triple
arthrodesis operation, as well as her small stature, also
render unlikely the possibility that she will learn to climb
or descend stairs without supporting herself on a bannister.
However, she learned essentially the same behavior in her
"obstacles" program; the five-inch platform was a shallow,
wide step. How much further could the program be pushed?
Claudia taught us that guessing does not provide the answer.
Programs That Failed
Self-care and hygience programs were neither Claudia's
forte nor ours. We attempted a toothb rushing program, based
on the observation that she enjoyed having her teeth brushed,
or so we naively surmised. What she enjoyed was the tooth-
paste. We began, as we did with most of her sessions except
those dealing with walking, by physically assisting her. The
simplest motion was side- to-side, but all attempts to fade
the assistance produced the same result. Claudia was rapidly
learning to chew her toothbrush. With this ignominious be-
ginning, we terminated the program. Even if we could teach
her simple brush strokes, how much longer would it take to
teach her to brush her teeth in a manner that would do them
some good? She would not benefit from what promised to be a
long, frustrating program. Our efforts were better directed
We abandoned the toothbrushing program after several
weeks, but were more tenacious in attempting to teach Claudia
dressing skills. T-shirts seemied the best place to start, as
pulling on a loose fitting T-shirt requires less force than
do most articles of clothing. Pulling on a shirt also lends
itself well to the popular "backward chaining" method (Bas-
singer et al. , 1971; Sundel & Sundel, 1975), in which the
complex behavior is divided into a sequence of simpler res-
ponses. The last response is taught first, then the next-
to-the-last response, and so on. The final response when
putting on a shirt is to pull it down once it has been slipped
over the head and arms. This was to be our first step in
Claudia's program. Unfortunately, to pull the shirt down
one must be holding it, which Claudia was not. For five
m.onths , we labored to induce her merely to hold the bottom
of the shirt. We gave up about four months after we probably
We did not attempt to teach Claudia any other dressing
skills. In retrospect, we were probably mistaken. Pulling
on socks, slipping on a coat, and other skills might have
been far easier to teach than pulling on a shirt. That we
did not attempt other dressing programs was no surprise. Our
first, extensive efforts were thoroughly unrewarded.
We were also tenacious-- and generally unsuccessful —
in an area unrelated to basic living skills: visual assess-
ment. When focusing on objects, Claudia's eyes diverged.
Our observations indicated that she primarily used her right
eye," and we sought to develop a rapid measure of visual acuity.
We developed a task in v/hich she was to choose a plain, white
block over a white block with a black spot. We failed in that
we did not develop a quick measure of resolution acuity, the
common means of visual assessment. However, we pursued the
project for more than a year to teach ourselves about the
experimental analysis of behavior. We eventually obtained
a measure of visibility acuity (detecting the presence/
absence of a stimulus; Christman, 1971). The results are
reported in the final chapter.
Programs Never Attempted
We taught — or attempted with varying degrees of success
to teach-- Claudia many of the basic elements of human be-
havior. However, we made none but the m.ost superficial
efforts in two major areas, toileting and speech.
When we arrived at Lilac, all but a few of the clients
v/ere in diapers. We successfully taught basic toileting
skills to some, but failed with others v/ho were generally
higher level than Claudia. Toileting is not an all-or-none
behavior. Accident frequency varies widely and can be sub-
divided into urination and defecation accidents. Self-
initiating may be beyond many clients' capabilities, but
these clients can be taken out of diapers if they eliminate
only when sent to the toilet on a regular schedule. Toilet
training frequently requires intensive training for days ,
weeks, or even months.
Based on our experience v/ith higher level clients, we
felt that we would be using much valuable training time with
Claudia in a program that offered little hope of success. To
keep her in or near the washroom for extended periods would
conflict with her progress in walking. Further, we were
actually making an effort to keep her out of the v/ashroom
since she, like many clients, drank from the toilet. It was
essential to keep the drinking to a minimum., both for health
reasons and because excessive liquid increased the probability
We did, however, begin placing her on the toilet after
meals to see if she might be susceptible to a schedule of
regular sending. After several months, she was no more likely
to urinate or defecate on the toilet than she was when we
began sending her, averaging overall a fifty percent "hit
rate." She showed no regular pattern of eliminating at other
times during the day. We continued the practice of sending
her, however, as it required little effort and did occasionally
save a diaper change.
We held little enough hope for toileting, but even less
for speech. Claudia was not deaf, as she demonstrated when
the cottage door opened at meal times. She certainly vocalized,
gurgling and crying at first, and later also laughing, but the
range of vocalizations was quite limited. Despite our strenu-
ous efforts to teach her to respond to her name, she responded
to it only occasionally after hearing it repeatedly for several
years. Our voices never exerted any consistent control over
her behavior. In short, we had observed that som.e behaviors
were likelier to occur than others, and speech was not one of
the likely ones'.
Deterraining the Limits of Training
Were the STARS Program to continue indefinitely, how much
more could Claudia learn? The preceding sections contained
speculation regarding training limits, but a definitive an-
swer is impossible. Victor, the Wild Boy, was still learning
when Itard terminated training after five years. Stoddard
did not find learning limits with Cosmo, the microcephalic,
after ten years (p. 18, ff.). Claudia's progress during tv/o
and a half years is perhaps only a beginning.
When we began teaching Claudia, our sole concern was to
stop the rumination, and we gave little thought to what miight
follow. Despite our naivete, we realized that Claudia was
exceptionally low functioning, even among the profoundly re-
tarded. Thus, v;e expected little of her. Our initial goals
for many other clients included basic speech, refined speech,
toileting, and academic and preacademic tasks. For Claudia,
eye contact was the first step, and that proved to be too
complex. Had we speculated during the first months of train-
ing, we would not have included walking to the cafeteria and
carrying a tray filled with solid food am^ong a list of feasible
goals. But Claudia v/as full of surprises, and the surprises
never ceased. We did not anticipate the speed with which
she acquired basic feeding and walking skills early in her
training; her social behavior was a later -surprise . As long
as the surprises continue, we cannot know- what Claudia's
The surprises do, however, suggest a rudimentary
criterion for predicting when the limits are reached. The
criterion is simply the cessation of surprises. When one has
"tried everything and nothing works," one can reasonably
speculate that the limits are near. A surprise negates the
speculation; lack of a surprise supports it.
One reduces surprises by carefully monitoring data, and
therein lies a more precise method of ascertaining the limits
of training. As one teaches a behavior or set of behaviors,
the following questions arise: Is there a change in behavioral
frequency ("celeration" ; see Pennypacker, Koenig, & Lindsley,
1972); that is, is the rate of appropriate behavior increasing
and/or the rate of inappropriate behavior decreasing? Is it
possible to successfully institute phase changes requiring
new or refined responses? If cueing or physical prompting is
used — as was often the case with Claudia-- can the prompt
be successfully faded? Will the behavior occur in conditions
other than training conditions, with or without explicit
programming? Have all reasonable tactics been tried to induce
the changes described in the foregoing questions?
Applying the analysis to one aspect of her ambulation
training, the obstacles program (pp. 115-119 and Figure 23),
we clearly did not approach Claudia's limit. We were able to
introduce many phases requiring successively more complex
behaviors. Within most of the phases, the frequency with which
Claudia crossed the obstacles either accelerated or maintained.
Simultaneously, the frequency of assistance 'decelerated. Al-
though we did not monitor with charted data her proficiency
at crossing obstacles outside of the session, we noted that
she began independently stepping up curbs following her
training with a similar obstacle (the platform) , In short,
the rate at which Claudia learned new obstacle-related be-
haviors gave us no reason to believe that we were approaching
her maximum possible performance.
In contrast, consider the data obtained during her fork
program (pp. 121-123 and Figure 24). We tried two unsuccess-
ful procedures. Although she was occasionally able to stab
her food independently, the frequencies of independent and
assisted stabs did not systematically change. Had we found
a behavior that Claudia could not perform? We pursued only
several of many possible training tactics. The data there-
fore suggest, but hardly confirm, a limit.
Similar analyses could be performed upon each program
in each aspect of Claudia's training. In some areas, we
possibly reached limits; in others, not. Our data, which
guided us throughout Claudia's training, led us to the notion
that "impossible" was not a viable concept. We tried, not
always successfully, to approach each new programi with no
preconceived notion of what she could learn. We occasionally
got nowhere. More often, Claudia rewarded us handsomely.
The Author Leaves the STARS Program
In the spring of 19 78, two and a half years after we
created the STARS Program, I was given an opportunity to
participate in a research project in another state. Saying
goodbye to staff and clients was difficult. We were a tight-
knit group and proud of the gains for which we had worked so
hard, I fretted over the clients under my care and reviewed
the program logic and procedures with those who would now be
I worried least about Claudia's training, which was to
become Marsha's responsibility. Marsha and I had worked to-
gether in planning Claudia's training since the beginning of
the program, and there was little to do except discuss pos-
sible future teaching efforts. Lorrie, Mardi, and Maureen,
who had worked extensively with Claudia, were still in the
program, and many of the remaining staff were also familiar
with Claudia. She would be left in competent, caring hands.
In fact, my only major concern was a selfish one. I did
not want to leave my friends; I did not want to leave my
clients, I especially did not want to leave Claudia, Her
progress had far exceeded my expectations, and she was still
learning. I wanted to know how much more she could grow, and
I wanted to be instrumental in that growth.
I vowed not to become maudlin on my last day with the
program. I returned Claudia to the cottage after supper.
seated her in a chair, kissed her, and left the living wing.
Halfway dovm the hall, I turned around and went back for one
last peek through the window in the door. As she often did
upon being returned to the cottage, she had walked to the
window and pressed her hands and face against it. Her in-
quisitive, innocent expression made it too hard to leave.
I opened the door, returned her to the chair, and walked out
again. I looked back and again she was approaching the door.
I forced myself to leave.
Claudia Leaves Lilac
Shortly after I left the STARS Program, the staff was
informed that grant funds were running out, and the program
would be terminated within a year. As original projections
had indicated at least another two years' operating time, we
had given little thought to the dismantling process. The
staff immediately set about the task of reducing training
time for the clients while monitoring to be sure that be-
havioral losses were minimized.
The STARS Program had always exclusively served clients
living in Lilac. When a client was transferred to a higher
level cottage, we had generally continued training for awhile,
gradually reducing the amount of time and making ourselves
available to consult with the new cottage's staff. Most,
though not all, of the clients fared quite well in their new
placements. Marsha chose the same tactic with Claudia, recog-
nizing that it would be dangerous to leave her in Lilac without
continued training. Lilac w&s crowaed^ filled with ip.ultiply
handicapped clients-. 'Allowing her to remain there where the
staff would have little time to spend with her would all but
guarantee severe behavioral regression.
Working with the director of the major training depart-
ment on campus, Marsha arranged a trial period for Claudia at
Lily, a slightly higher level ICF/MR (Intermediate Care Facil-
ity for the Mentally Retarded) cottage. The placement was
significant — ICF/MR cottages are governed by strict federal
regulations requiring a higher staffing ratio, better physical
facilities, and more programming time for the clients than are
found in non-ICF/MR units. During the trial period of several
weeks, Claudia spent her days at Lily and continued to sleep
at Lilac. The trial period was successful, and in September,
1978, Claudia was accepted for residency at Lily. In February,
1979, all Lily clients were moved so that Lily could undergo
ICF/MR-directed renovation, scheduled for completion in 19 80.
Claudia and her Lily peers thus currently reside at Hope Cottage.
During the Lilac- to-Lily transition period, Marsha, too, left
the STARS Program, and Lorrie, Mardi, and Maureen assumed res-
ponsibility for Claudia's training.
Claudia functions at a somewhat lower level than most of
her Lily/Hope cottagemates. Many can speak, respond to spoken
commands, and are toilet trained, ICF/MR regulations specify
that clients will not wear diapers, and Claudia was therefore
placed in pants. She is sent to the toilet regularly, and is
reported to have "few" accidents; Lily/Hope staff estimates
are one or fewer per day. Whether this is the result of her
previous "sending" program, or whether the staff simply sends
her often enough (she does not eliminate frequently) , we do
not know, but her toileting behavior is acceptable to the
ICF/MR clients do not attend the campus cafeteria, but
Claudia's cafeteria and feeding programs were essential in
her placement. The cottage staff gradually replaced STARS
trainers in her feeding program. When Claudia moved to Lily,
STARS trainers were with her for about two hours per day and
ten to fifteen meals per week. By January, 1979, STARS time
was reduced to about 15 minutes following breakfast and lunch
on weekends, and the Lily/Hope staff was completely responsi-
ble for the mealtime program. While the cottage staff is not
currently collecting data, it is insuring that Claudia re-
tains eating and related skills. For example, clients are
required to carry their trays into the kitchen after meals,
and at this task Claudia is quite proficient. Additionally,
anecdotal information indicates further reduction in the num-
ber of Claudia's spills while drinking.
As the STARS workers reduced their time with Claudia, it
was necessary to find activities to fill the vacancy created
in her schedule. Mornings were no problem; Julia still
arrives daily to take Claudia out. Their outings should be
sufficient to maintain most of Claudia's ambulation skills.
Afternoons proved to be more difficult. In October, 19 78,
Claudia was briefly enrolled in the Sunland school, where she
V7as given generally unstructured gross motor tasks. Her
enrollment v/as terminated after about a month. The school,
like STARS, is funded by 89-313 grant monies, and regulations
forbid clients simultaneously to receive services from two
89-313-funded organizations. In addition, Claudia's school
setting did not provide structured, individualized training.
Not surprisingly, Claudia failed to progress in school.
By early February, 1979, STARS time with Claudia was
sufficiently reduced to allow her to re-enter school without
89-313 funding conflict. It is to be hoped that she will re-
ceive more structured training than she did previously so
that she can remain in school.
Claudia's programming time is not limited to excursions
with Julia and attending school. She continues to participate
in STARS field trips, and former STARS staff who have taken
jobs elsewhere on the campus visit her and take her for off-
cottage and off-campus outings.
The chief concern of all of us who worked with Claudia
is, of course, the rumination. The remaining STARS time is
devoted to teaching the Lily/Hope staff to monitor the ru-
mination and maintain the cheek-hold procedure. Since the
cottage staff does not keep a rumination chart, the success of
maintaining control will be difficult to judge. Claudia still
does not ruminate often in the presence of STARS trainers
(Figure 27, phase N) . Much of the apparent charted increase
in frequency is an artifact of the charting procedure: fre-
quencies of zero are charted according to the amount of
3j.nNJ!f< Had iwnoo
training time; less training time raises the estimated frequency.
However, there are also more days now during which Clau-
dia does ruminate in the presence of a trainer. Cottage per-
sonnel report that they implement the cheek-hold procedure,
although not as consistently as did STARS trainers. The
available data thus suggest that the rumination is increased
V7hen trainers are not present. Efforts are underway to rec-
tify the problem. STARS trainers are teaching the Lily/Hope
staff the importance of consistent intervention. The task is
not easy. Rumination is common at Sunland and is not a sig-
nificant problem for many clients who ruminate at a low fre-
quency and do not evidence weight loss. To the cottage staff,
Claudia is one such client. She is healthy, does not ruminate
often, and her weight is stable at 85 to 9 pounds (see
Figure 6b, p. 48). We observed the problem before among
staff who began working with the STARS after Claudia's rumina-
tion was already under control. Now the Lily/Hope staff must
learn about the consequences of failing to intervene. Their
learning is the key to the fruition of nearly three years of
work with Claudia.
Claudia is undergoing major environmental changes. In
19 75, she was deteriorating in the Lilac environment. She
thrived in the subsequent Lilac/STARS environment, and con-
tinued to thrive as she made the transition to the Lily/Hope/
STARS milieu. Soon, formal STARS input to her training will
be. terminate.d. To. da,te, she is doing well. Her new circum-
stances seem supportive of the changes we induced in her.
She is required to feed herself and carry her tray, so
the feeding and related skills should maintain and perhaps
improve. She will probably retain most of her ambulation
skills under Julia's auspices and because of her old trainer-
friends' visits. Hov/ever, formal ambulation training has
been terminated, and she walks shorter distances, over fewer
obstacles than she did previously. Some of her skills may
deteriorate. Her social behaviors may or may not maintain.
She receives less attention and physical contact than she did
during intensive STARS training. But she still sees Julia
and the other grannies, her friends visit, and the higher
level Lily/Hope clients attend to her more frequently and
appropriately than did her Lilac peers. A positive sign is
that she now spends more time sitting on the couch with her
cottagemates , an improvement over her preference for the Lilac
day room, floor.
Her continued wellbeing hinges upon the rumination. Here,
the data are less definitive. She is currently healthy, but
more time is needed to determine whether the cottage staff
can control this salient aspect of Claudia's behavior.
I continue to worry and wonder what the future will bring
for Claudia, and I fervently hope for the best for her. We
taught her many things, but she gave us much more in return.
She taught us, inspired us, and we came to love her dearly.
Between visits, I'll miss her.
DETERMINATION OF VISUAL THRESHOLDI
Claudia's eyes diverged and informal observations by her
trainers indicated that her right eye was dominant. At her
yearly eye examination in 19 77, the doctor confirmed that,
based upon measures of light refraction, her left eye vision
was probably considerably poorer than that of her right eye.
He also commented that adequately assessing the vision of in-
dividuals functioning at Claudia's level was a difficult task.
We became interested in the problem and attempted to devise a
procedure that would relatively rapidly and accurately assess
Claudia's vision. We realized v/ithin several weeks that, at
least for Claudia, the procedure was not a quick, convenient
one. We continued to pursue the problem, however, as we were
curious to discover whether we could calculate any sort of
visual threshold measure. Claudia's extensive training sched-
ule allowed us ample time to spend the several minutes per day
necessary to conduct the visual training and testing.
Assessing the vision of severely retarded, handicapped
individuals is difficult, primarily because many such in-
dividuals do not respond to verbal instructions. In addition.
iThe author wishes to thank Dr. C. K. Adams for his en-
couragement and consultation throughout this project. His
assistance was indispensable in developing the final experi-
these individuals may be easily distracted, and their handicaps
can severely limit the nature of the response used for assess-
ment (Faye, 1968; Langley & DuBose, 1976). The problem is
particularly important since visual impairment frequently
accompanies retardation and other handicaps (Blackhurst &
Radke, 1968; Wolf & Anderson, 1973; Langley & DuBose, 1976).
Available techniques for assessing handicapped popula-
tions generally require responses that are too complex for
profoundly retarded individuals. The responses are commonly
centered around choosing or matching various toys, simple
shapes, and pictures (Faye, 1968; Lippman, 1969). For lower
functioning individuals, operant assessment procedures are
more promising since the response is usually simple to exe-
cute and primary reinforcement insures that the subject will
emit enough responses to be assessed. Sidman and Stoddard
(1967; and Stoddard & Sidman, 1971), for example, were able
to obtain visual acuity measures from retarded subjects by
establishing a circle-ellipse discrimination and gradually
making the ellipse more circular, Macht (1971) developed
a procedure in which lever presses caused a circle to rotate.
Subjects learned to upright a Snellen E printed on the circle,
Newsom and Simon (19 77) reported a simpler procedure.
The response involved walking dov;n one of two short passage-
ways and touching a stimulus card at the end of the passage-
way. One passageway contained S+ , originally a card with
vertical black and white stripes, faded in two steps to a
Snellen E rotated 9 0° (pointing downward) . The other
passageway contained S-, originally a blank card, faded in 18
steps to a backwards Snellen E. Praise and an edible rein-
forcer were delivered for each correct choice; the child was
told to sit down each time he or she entered the wrong pas-
sageway. Progressively smaller stimulus pairs were used to
determine visual resolution acuity. Of eleven nonverbal,
autistic and schizophrenic Ss_, eight were successfully
trained and tested, each requiring no more than three hours
(one to three sessions) . The remaining three S_s failed to
make a horizontal-vertical stripe discrimination during
training and could not be tested.
Training the Basic Response
We chose depositing blocks in a can as the basic response.
When we began training we were not sure what the final test
stimuli would be. We preferred instead to postpone this de-
cision until we isolated a visual dimension to which Claudia
would reliably respond and that we could accurately quantify
in increments small enough to obtain a discrimination mea-
sure. We decided only that the task would involve choosing
one of two blocks over repeated trials.
We trained Claudia to pick up a 2.54-cm^ Cone cubic
inch) wooden block and deposit it in an empty peanut butter
can (institutional size, 17,78 cm diameter). Training re-
quired three days, ten minutes per day. Claudia initially
reached for the block and picked it up when it was placed in
front of her; the trainer merely guided Claudia's hand over
the can and induced her to release the block. She received
a spoonful of food for each block deposited. During the
first day, Claudia needed assistance of this nature on ap-
proximately one block per minute, while she independently
deposited about four blocks per minute. By the third day,
she needed assistance with only two blocks (0.2 blocks per
minute) and independently deposited seven blocks per minute.
She used her right hand almost exclusively during training
and throughout the study.
We next constructed the experimental apparatus, a
45.72-cm length of two-by-four board, to which we glued two
small plastic cups, 15.24 cm apart. The cups were filled
with Play Dough so that each wooden block would protrude
1.59 cm above the cup rim.. The entire apparatus was painted
The trainer and Claudia sat on the floor facing each other
across a small coffee table, on which the trainer placed the
apparatus, and to Claudia's right, the peanut butter can.
The trainer placed one block at a time into one of the cups,
alternating cups. During the first day, Claudia repeatedly
grabbed both block and cup, ripped the cups off the board.
We fortified the apparatus and repainted it. The next day we
began with the block on the tabletop, next to the apparatus.
Over ten trials Cone trial = depositing one block in the can) ,
we moved the block from the tabletop, onto the apparatus (but
not in the cups), and finally into the cups. During the
remainder of the session, she deposited 55 blocks in ten
minutes, 40 seconds, grabbing the cup 20 times in the process.
The frequency and apparent (but unmeasured) force with which
she grabbed the cup decreased during the session and were no
longer a problem at the end of the session. The problem did
not reappear during the course of the study.
Discrimination training and testing were conducted in
Lilac's lounge. Sessions began between 4:00 and 4:30 p.m.
and usually lasted seven to ten minutes. Claudia's schedule
usually permitted three to five sessions per week. The ses-
sions V7ere conducted before her other afternoon training ses-
sions to minimize fatigue and maximize the effects of the
reinforcer. The window curtains were closed during the
sessions so that the only light source was overhead fluores-
cent lighting. Light level on the apparatus was 16 foot-
candles (measured with light meter installed in Honeywell
Pentax Spotmatic camera) , During the first half of the train-
ing phase, Claudia was seated at the coffee table, as described
above; during the second half of training and throughout test-
ing, she was seated in the relaxation chair. She m.aintained
a constant posture in the relaxation chair, head slightly
tilted forward, eyes 40 - 45 cm from the stimulus blocks.
Other trainers and clients, staff, and visitors were occasional-
ly in the lounge but were apparently not distracting; Claudia
rarely looked up v;hile the sessions were in progress.
The discrimination task involved lifting and depositing
in the can one of two blocks (S+,. S-) presented simultaneously
in the apparatus cups. The trainer tallied correct and in-
correct responses on a record sheet which indicated whether S+
was placed in the right or left cup. Sessions consisted of 40
trials Cincreased to 50 trials during the final testing phase)
of random right and left placements. The randomdzation was
modified to insure an equal number of right and left place-
ments and that S+ was never placed' on the same side more than
four times in succession. The trainer timed each session with
a stopwatch, beginning the timing when the first pair of
stimulus blocks was presented and ending the timing when the
final block v/as deposited in the can. The watch did not run
during timeout periods (see below) , Data were thus available
regarding the numJDer and frequency of S+ and S- choices, as
well as regarding conditional probabilities (probability of
choosing S+ in right versus left cup, etc.).
The first training phase involved discriminating solid
white (S+) and solid black (S-) blocks. Each time Claudia
deposited the S+ block in the can, she was given a spoonful
of food; if she picked up the S- block, the trainer took it
away before she could deposit it and removed the apparatus
(timeout, TO) for 15 seconds. Immediately follov/ing either
food delivery or 15 second TO, the next pair of blocks was
presented. Thus, although the session consisted of discrete
trials, or block presentations, the trials occurred as rapidly
as Claudia's and the trainer's behavior permitted, rather than
on a time-based schedule. At first Claudia chose S+ more
frequently than S-, but the discrimination deteriorated
rapidly (Figure 28, phase A) 1.
A large part of the problem appeared to be that Claudia
was "grabby" between trials. As soon as she deposited a block
and received a reinforcer, she began reaching for the appara-
tus and would take the first block inserted into a cup. We
used a cardboard screen for several days in an effort to
alleviate the problem. Although her performance improved,
(phase B) , the grabbing continued, this time directed at the
screen. When the trainer removed the screen, Claudia fre-
quently took the block nearer her hand. We eliminated the
screen and solved the problem by instituting a "distracting
response" (phase C) . Before each trial, the trainer placed
an orange wooden block (one cubic inch) in front of the
apparatus. While Claudia deposited the block in the can, the
trainer arranged the stimulus blocks. A trial therefore con-
sisted of depositing one orange and one stimulus block. No
training was required to induce Claudia to deposit the orange
blocks. This arrangement remained in effect for the duration
of the study.
-'-While Fig. 2 8 records the frequency of St and S- choices,
percent correct is readily derived. Where S- responses are
indicated, percent correct is obviously 100. In other cases,
percent correct is calculated by obtaining the ratio of S+ to
S- choices; on the logarithm.ic frequency scale, the ratio is
the distance between S+ and S- frequencies. Percent correct =
(ratio) T (ratio + 1). For example, if S+ rate = 6 per min,
and S- rate = 2 per min., ratio =6^2=3, and percent cor-
rect = 34-4 = 0.75, or 75%.
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Although the grabbing was greatly reduced, Claudia
reached for the stimulus block on her right in a dispropor-
tionately high number of trials. The side preference had
existed since the start of training, but v/orsened shortly af-
ter we introduced the distracting response. It is not clear
whether the distracting response and the preference were
related. The side preference is illustrated in Figure 29a,
the probability of a correct response when S+ was in right
versus left cup, and Figure 29b, the probability with which
Claudia reached for the right block regardless of whether
the block was S+ or S-. When Claudia reached for the right
block nearly 100% of the time, we placed the can on her left
side. Although the preference temporarily disappeared, it
soon returned (Figure 28, phase D ; Figures 29 a,b) . We now
glued the S- block into one of the cups and rotated the entire
apparatus to effect right and left presentations. The side
preference disappeared permanently (Figures 29 a,b) .
When we glued the S- block, we removed the TO contingency
since Claudia obviously could not lift the incorrect block.
Instead, we let her pull at the S- block and correct her error;
she received reinforcement for depositing the S+ block whether
or not she had first pulled at the S- block. Her performance
gradually deteriorated (Figure 28, phase E) . We altered the
contingencies; depositing S+ still resulted in reinforcement,
but the apparatus was removed for 15 seconds (TO) as soon as
Claudia's hand touched S-. After a week her performance
began improving (phase F) .
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When she was responding to S- about 0.2 5 times per minute
(about three responses per 40 trials) , we reversed S+ and S-
so that S+ was nov/ the black block. S- , the white block, was
covered entirely by gray tape. The same contingencies were in
effect; depositing the black block resulted in reinforcement
and touching S- (actually the gray tape) resulted in a 15
second TO. Although the S- block V7as not even visible, she
reached frequently at first for the gray tape (phase G) . She
rapidly learned to pick up the black block, and we removed the
tape from S-. We did not glue the white block, however. In-
stead, if she picked it up, it was taken away from her and
a 15 second TO ensued, (same procedure as that of phase A,
except S+ = black and S- = white) . Her performance rapidly
degenerated (phase H) .
Since Claudia had learned so quickly to avoid the block
with gray tape, we retaped the v/hite block (phase I) . This
time, however, the tape was a strip 1.59 cm thick, running
from the lip of the cup over the top of the block and down to
the lip on the opposite side, so that the tape formed a verti-
cal gray stripe over the block. We then decreased the thick-
ness of the tape in steps, 0.64 cm, 0.32 cm. and 0.16 cm.
At 0.16 cm we colored the tape black. Apparatus removal for
15 seconds contingent upon touching S- was reinstated. The S-
block was glued during this phase, as the thin tape strip could
not prevent her from removing the block if she grabbed it
firmly before the trainer could remove the apparatus.
We finally realized that the tape could be used to estab-
lish a discrimination for threshold measurement. A white
block with black tape was still S-, and S+ became a plain
white block (phase J) . We began conducting sessions in the
relaxation chair and removed the part of the tape fastened to
the lip of the cup. Instead, the tape ran over the top of the
block and down its sides. Claudia performed almost errorlessly
(phase K) . We gradually removed the tape from the sides of the
block (phase L) , running it 1,27 cm down each side, then just
barely over the top edges of the block, finally shortening and
widening the tape until it was roughly hexagonal, 1,27 cm long
and 0.79 cm wide, on top of the block. We also removed the
glue and replaced it with Velcro patches to hold S- firmly
in place. Nonstick material was placed on S+ blocks to equate
the height of S+ and S-. Thus, S- could be moved from cup
to cup between trials, eliminating the possibility that
Claudia could be responding to some aspect of the cup in
which S- was placed. We were ready to begin testing.
Testing, Retraining, and Retesting
We prepared the series of test stimuli. A v/hite block
continued to serve as S+, and the S- series was a set of nine
blocks, each white with a black (India ink) circle in the top
center of the block. The circle diameters were: 0.56 cm
(7/32 inch), 0.48 cm (3/16), 0,40 cm (5/32 inch), 0.32 cm
(1/8 inch), 0.24 cm (3/32 inch), 0.16 cm (1/16 inch), 0.12 cm
(3/64 inch), 0.08 cm (1/32 inch), and 0.04 cm (1/64 inch). ■
The stimuli are henceforth designated 7, 6, 5, 4, 3, 2, 1, 0.5.
All S- blocks v/ere equipped with Velcro patches.
We switched to a VR2 schedule of reinforcement, •
anticipating that Claudia would begin making errors as the
stimuli approached her threshold; all errors still resulted in
a 15 second TO (phase M) . We began using only block 7 and over
several days introduced blocks 5, 5, and 4. The same stimulus
was presented over four consecutive trials, and the order of
stimuli was mixed (e.g., four 7's, four 4's, four 6's, etc.).
The procedure was thus a variation of the constant-stimulus
and constant-stimulus difference methods popular in psycho-
physics (Christman, 1971) .
Each session v/as 40 trials as was the case during train-
ing. As Claudia was making few errors at any of these S-
values , we eliminated the 7 and 6 blocks and inserted eight
trials with the 3 block, then eight trials with the 2 block.
On the day we added the 2 block, her error frequency was 1. 8
per minute; the previous day it had been 0,9 per minute.
Most of the errors occurred on the 2 block. The next day her
error frequency rose again, and again most of the errors
occurred on the 2 block. The following day, although she
made more correct than incorrect responses, the discrimination
was largely lost, as errors appeared at all S- values. We
had probably added the smaller S- dots too rapidly.
We consequently undertook retraining (phase N) . We re-
turned to reinforcing every correct response and used only
blocks 5, 5, and 4. We did not regain control, and therefore
eliminated blocks 5 and 4 and added an S- block with a black
tape patch similar to the tape patches used prior to testing.
This was sufficient to reestablish control, and we eliminated
the tape patch, returned to a VR2 reinforcement schedule, and
included trials using blocks 5 and 4. We increased the nuniber
of trials per session to 60 and eliminated the 6 block. We
were again ready to test, i.e., add blocks 3, 2, 1.5, 1, and
0.5. The entire retraining process had taken five weeks.
During the second testing period (phase C) , which lasted
six and a half weeks, we added the smaller S- blocks at a
slower rate than we had previously. In addition, we presented
a given S~ only twice in succession, taking care to present
larger dots immediately before and after the smaller ones.
Claudia's error rate never exceeded 1.5 per minute. During
the final several weeks of testing, each session consisted of
30 presentations of the 5 block, six 2's, eight 1.5's, eight
I's, and eight 0.5's (the 3 and 4 blocks were eliminated as
Claudia nearly always responded correctly; the 5 block re-
mained to insure that she did not lose the discrimination) .
Testing was discontinued at the end of May due to major
structural changes in the STARS Program, Consequently, thresh-
old values were never determined for right and left eyes
The results of the second testing series (phase 0; 4/7/78-
5/19/78) are displayed in Figure 30. The data are divided
into four curves according to the dates listed on the figure.
The divisions were chosen as follows: Triangles represent
data taken v/hen blocks 5, 4, 3, 2, 1, were used; squares
represent data taken on all seven blocks; filled circles are
.I^S' &13 4S
Fig. 30. Percent correct choices as a function of diameter
of S- dot. The four curves represent data taken during
successive periods of testing, as indicated in the key,
above. The columns containing numbers of trials correspond
to the S- dot sizes under which the columns appear.
data taken on all seven blocks, but while the 4 block was being
eliminated, open circles represent data taken on blocks 5, 2,
1.5, 1, 0.5.
The curves move generally upward through time, indicating
that Claudia was becoming progressively more sensitive to the
smaller stimuli. However, the last two curves are extrem.ely
close; she was probably discriminating maximally. Since the
procedure involved choosing one of two blocks, 50% correct
is not an appropriate threshold criterion. Instead, the
threshold line is taken to be 75%. The line passes precisely
through the 0.0 8 cm value for the last of the curves; her
threshold is therefore 0.0 8 cm. At 42.5 ± 2.5 cm from
Claudia's eyes, the threshold stimulus subtended 0.10 8 t
0.006° , or 6.47 + 0.40 min of visual angle.
Using the 6.47 min of visual angle subtended by the
threshold stimulus, it is possible to approximate the familiar
Snellen acuity ratio. The Snellen ratio for "normal" vision,
20/20, indicates that the subject can resolve a separable angle
of one min; 20/40 means that the subject requires twice the
norm.al separation, or two min; 20/200 is a ten-min angle,
and so on. Since Claudia reliably detected a stimulus sub-
tending 6.47 min of angle, the approximate Snellen ratio is
20/130, For the purposes of comparison, in most states, an
individual must have corrected vision of 20/40 or better to
obtain a driver's license; persons with corrected vision of
less than 20/200 are considered legally blind (.Massachusetts
Department of Medical Affairs, personal communication) .
The ratio calculated for Claudia must be interpreted
cautiously, however. Resolution acuity, which the Snellen
ratio measures, refers to the subject's ability to detect a
separation between the components of a stimulus. For example,
all segments of the Snellen "E" are one min in width, and
each segment is separated by a one-min space. In comparison,
Claudia was detecting the presence/absence of a single-
component stimulus, a circle. To obtain a more accurate es-
timate of the Snellen ratio for Claudia, we would have had to
use multi-component stimuli, for example, two horizontal
stripes and two vertical stripes.
Although we successfully established a visual threshold
for Claudia, the study was a failure in several respects. The
original aim was to devise a rapid (several days to several
weeks) means of measuring visual acuity. The project lasted
just over a year and produced a measure of visibility acuity
(presence/absence of a stimulus) that can only tenuously be
converted to the common measure of visual functioning, reso-
lution acuity. The procedure would presumably have taken
less time with higher level clients and would also likely re-
quire less time to replicate with a client of Claudia's level,
based on what we learned from the present study. However, the
procedure devised by Newsom and Simon, discussed in the intro-
duction, requires less time and directly produces a resolu-
tion acuity ratio. Thus, Newsom and Simon's procedure would
proba,l3ly b,e the method of choice with higher functioning
For individuals functioning at Claudia's level, those
who would not likely be testable with other procedures, more
data are required regarding the usefulness of the present
procedure. By how much could the procedure be shortened?
What problem.s might be involved in testing each eye separately?
We successfully trained Claudia to wear a patch on either
eye in anticipation of the present study, but whether she
would have performed the discrimination task, particularly
with her dominant eye covered, is a matter of speculation.
The problems encountered during the study would certainly
lead one to suspect that testing the weaker eye would have
produced further problems,
A different line of questioning addresses the useful-
ness of detailed visual assessment for lower functioning in-
dividuals. In the absence of procedures such as those dis-
cussed in the introduction, an opthamologist ' s examination,
requiring no behavior from the subject other than keeping the
eyes open, reveals gross impairments or physical damage to
the eyes. How much further information is useful or necessary?
Claudia functioned well enough in her regular training ses-
sions. How much, if at all, better would she have fared were
her vision assessed and corrected? Would she have learned to
walk more rapidly with corrected vision, especially in pro-
grams such as step-climbing and obstacles, which required her
to discriminate edges and contours? The answers to such
questions require a means of testing and correcting vision.
The present study is a beginning.
The study was also useful in another sense. All of us
involved in it learned much about the experimental analysis
of behavior. We were tempted to abandon the study many times,
particularly since it was not an integral part of Claudia's
training. However, the problem intrigued us, and the sessions
required little time per day. We were disappointed that we
did not achieve our original aims, but we were not sorry that
we attempted the project.
Allen, K. E., Hart, B. , Buell, J. S,, Harris, F. R. , and
Wolf, M. M. Effects of social reinforcement on isolate
behavior of a nursery school child. Child Development ,
1964, 21, 511-518.
Arrington, R. E. Time- samp ling studies of child behavior.
Psychological Monograms , 1939, 52-_, No. 228.
Axline, V. M. Dibs in search of self . New York: Ballantine,
Ayllon, T. Intensive treatment of psychotic behavior by
stimulus satiation and food reinforcement. Behavior
Research and Therapy , 1963, 1_, 53-61,
Ayllon, T. Some behavioral problems associated with eating
in chronic schizophrenic patients. In L. P. Ullman and
L. Krasner (Eds.), Case studies in behavior modification .
New York: Holt, Rinehart, & Winston, 1965.
Ayllon, T., and Azrin, N. H. The measurement and reinforce-
ment of behavior of psychotics. Journal of the Experi -
mental Analysis of Behavior , 1965, _8, 357-383.
Ayllon, T., and Azrin, N. H. Reinforcer sampling; A tech-
nique for increasing the behavior of mental patients.
Journal of Applied Behavior Analysis , 1968, 1_, 13-20.
Ayllon, T., and Michael, J. The psychiatric nurse as a be-
havioral engineer. Journal of the Experimental Analysis
of Behavior , 1959, 2_, 323-334.
Azrin, N. H. , and Holz , W. C. Punishment. In W. K. Honig
(Ed. ) , Operant behavior: Areas of research and applica-
tion . New York: Appleton-Century-Crof ts , 1965.
Azrin, N. H, , and Lindsley, 0. R, The reinforcement of co-
operation between children. Journal of Abnormal and
Social Psychology , 1956, 52^, 100-102.
Barker, R. G. , and Wright, H. F, ' Psychological ecology and-
the problem of psychosocial development. Child Develop-
ment, 1949, 20, 131-143.
Barrett, B. H. Reduction in rate of multiple tics by free
operant conditioning methods. In L. P. Ullman and
L. Krasner (Eds.), Case studies in behavior modifica-
tion . New York: Holt, Rinehart, and Winston, 1965.
Barton, E. S., Guess, D,, Garcia, E, , and Baer, D. M. Im-
provement of retardates' mealtime behaviors by timeout
procedures using multiple baseline techniques. Journal
of Applied Behavior Analysis , 1970, 3_, 77-84.
Bassinger,. J. F., Ferguson, R. L. , Watson, L. S., and V7yant,
S , I . Behavior modification: A programmed test for in-
stitutional staff . Libertyville, IL: Behavior Modifi-
cation Technology, Inc., 1971.
Becker, J. V., Turner, S, M. , and Sajwaj , T. E. Multiple'
behavioral effects of the use of lemon juice with a
ruminating toddler-age child. Behavior Modification ,
1978, 2_, 267-278.
Beers, C. A mind that found itself . New York: Doubleday,
Bijou, S. W. A systematic approach to an experimental analysis
of young children. Child Development , 1955, 26_, 161-168.
Bijou, S. W. Methodology for an experimental analysis of
child behavior. Psychological Reports , 1957, _3/ 243-250.
Bijou, S. W. Operant extinction after fixed-interval sche-
dules with young children. Journal of the Experimental
Analysis of Behavior , 1958, J^, 25-29.
Blackhurst, R. , and Radke, F. Vision screening procedures
used with mentally retarded children — A second report.
Sight Saving Review , 1968, 3_8, 84-88.
Breger, L. , and McGaugh , J. L. Critique and reformulation of
"learning theory" approaches to psychotherapy and neu-
rosis. Psychological Bulletin , 1965, 6_3, 338-358.
Breger, L. , and McGaugh, J. L. Learning theory and behavior
therapy; A reply to Rachm.an and Eysenck, Psychological
Bulletin , 1966, 65^, 170-173.
Christman, R, J. Sensory experience . Scran ton, PA: Intext
Educational Publishers, 1971,
Cunningham, C, E,, and Linscheid, T, R, ' Elimina,tion of
chronic infant ruminating by electric shock. Behavior
Therapy, 1976-, 7, 231-234.
Darwin, C. A. A biographical sketch of an infant. Mind,
Emurian, H. H., Emurian, C. S., and Brady, J. V. Effects of
a pairing contingency on behavior in a three-person
programmed environment. ' Journal of the Experimental
Analysis of Behavior , 1978, 2_9_, 319-329.
Epstein, L. H., Doke, L. A., Sajv/aj , T. E., Sorrell, S., and
Rimmer, B. Generality and side effects of overcorrection.
Journal of Applied Behavior Ana lysis, 1974, 1_, 385-390.
Evans, J. Three men . New York: Vintage Books, 1966.
Faye, E. E. A new visual acuity test for partially-sighted
nonreaders. Journal of Pediatric Opthamology , 1968,
Ferster, C. B., and DeMyer, M. K. A method for the experi-
mental analysis of the behavior of autistic children.
In L. P. Ullman and L. Krasner (Eds.), Case studies in
behavior modification . New York: Holt, Rinehart, and
Findley, J. D. Programmed environments for the experimental
analysis of human behavior. In W. K. Honig (Ed.), Oper -
ant behavior: Areas of research and application . New
York: Appleton-Century-Crofts , 19 66.
Flavell, J. H. The developmental psychology of Jean Piaget .
Princeton, NJ: Van Nostrand, 1963,
Foxx, R. M. Attention training: The use of overcorrection
avoidance to increase the eye contact of autistic and
retarded children. Journal of Applied Behavior Analysis ,
1977, 10_, 489-499.
Foxx, R. M., and Azrin, N. H. The elimination of autistic
self-stimulating behavior by overcorrection. Journal of
Applied Behavior Analysis , 1973, 6_, 1-14.
Freud, S. From the history of an infantile neurosis ('The
Wolf Man' ) . The standard edition of the complete psycho -
logical works of Sigmund Freud . London: Hogarth Press,
1955, Vol. XVII.
Fuller, P. R. Operant conditioning of a vegetative human
organism. American Journal of Psychology , 1949, 62 ,
Hahn, E. A. A reporter at large: Getting through to others — 1,
New Yorker, April, 1978, 38-103.
Harris, F. R. , Johnston, M. K., Kelley, C. S., and Wolf, M. M.
Effects of positive social reinforcement on repressed
crawling of a nursery school child. Journal of Educa -
tional Psychology , 1964, 55_, 35-41.
Harris, S. L., and Romanczyk, R. G. Treating self-injurious
behavior of a retarded child by overcorrection. Behavior
Therapy , 1976, l_r 235-239.
Hart, B. M. , Allen, K. E., Buell, J. S., Harris, F. R. , and
Wolf, M. M, Effects of social reinforcement on operant
crying. Journal of Experimental Child Psychology , 196 4,
Hartman, W. M. Time-sampling in the measurement of human
behavior. Unpublished area paper, University of Florida,
Horner, R. D., and Baer, D, M. Multiple probe technique: A
variation of the multiple baseline. Journal of Applied
Behavior Analysis , 1978, 11, 189-196.
Itard, J. M. G. First developments of the young savage (1801) .
A report made to his Excellency the Minister of the In-
terior (1806) . Translated and edited by G. Humphrey and
M. Humphrey as The wild boy of Aveyron . New York:
Appleton-Century-Crof ts , 1962..
Iwata, B., and Lorentzson, A. M. Operant control of seizure-
like behavior in an institutionalized retarded adult.
Behavior Therapy , 1976, 7, 247-251.
Johnston, J. M. , and Pennypacker, H. S. Strategies and tactics
of human behavioral research . In press.
Jones, E. The life and work of Sigmund Freud; Vol. 2 . New
York: Basic Books, 1955.
Jones, M. C. A laboratory study of fear: The case of Peter,
Journal of Genetic Psychology , 1924, 31.' 308-315.
Kanner, L. Child psychiatry . Springfield, IL: Chas . C.
Kazdin, A. E. History of behavior modification . Baltimore:
University Park Press, 1978.
Kelleher, R. T., and Morse, W, H. Schedules using noxious
stim.uli. III. Responding maintained V7ith response-
produced electric shocks. Journal of the Experimental
Analysis of Behavior, 1968, 11, 819-838.
Koegel, R. L. , and Rincover, A. Research on the difference
between generalization and maintenance in extra-therapy
responding. Journal of Applied Behavior A nalysis, 1977,
iQ_, 1-12. " : '
Kozloff, M. A. Reaching the autistic child. A parent train -
ing program^ Chairipaign, IL: Research Press, 19 73.
Krumboltz, J. D. , and Krumboltz, H. B. Changing children's
behavior . Englewood Cliffs, N J : Prentice-Hall, 1972.
Lane, H. The wild boy of Aveyron . New York: Bantam, 19 76.
Lang, P. J., and Melamed, B. G. Avoidance conditioning thera-
py of an infant with chronic ruminative vomiting. Jour-
nal of Abnormal Psychology , 1969, 7_4, 139-142.
Langley, B. , and DuBose, R. F. Functional vision screening
for severely handicapped children. The New Outlook ,
October, 1976, 346-350.
Lazarus, A. A. The results of behaviour therapy in 126 cases
of severe neurosis. Behavior Research and Therapy , 1963,
1, 69-79. ' " ^~
Lindsley, 0. R. Daily behavior chart. Journal of Applied
Behavior Analysis , 1968, _1, inside back cover.
Lippman, 0. Vision of young children. Archives of Optha-
mology, 1969, 81, 763-767.
Locke, J. An essay concerning human understanding . Edited
by A. S. Pringle-Pattison. Oxford: Clarendon Press,
Lovaas, 0. I,, and Simmons, J. Q. Manipulation of self-
destruction in three retarded children. Journal of
Applied Behavior Analysis , 1969, 2_, 143-157.
Loynd, J., and Barclay, A. A case study in developing ambu-
lation in a profoundly retarded child. Behavior Research
and Therapy , 1970, £, 207.
Lytton, H, Observation studies of parent-child interaction:
A methodological review. Child Development , 19 71, 42,
Macht, J. Operant measurement of subjective visual- acuity in
non-verbal children, Journal of Applied Behavior Analysis ,
1971, 4_, 23-26.
Miller, H. R,, Patton, M. E., and Henton, K. R. Behavior
modification in a profoundly retarded child: A case
report, ' Behavior Therapy , 1971, 2_, 375-384.
Morse, W. H., and Kelleher, R. T. Schedules as fundamental
determinants of behavior. In W. N. Schoenfeld (Ed.),
The theory of reinforcement schedules . New York: Apple-
ton-Century-Crofts, 19 70.
Mussen, P. H. , Conger, J. J., and Kagan, J. Child develop -
ment and personality . New York: Harper and Row, 1969.
Newsom., C. D., and Simon, K. M. A simultaneous discrimination
procedure for the measurem.ent of vision in nonverbal
children. Journal of Applied Behavior Analysi s, 19 77,
Patterson, G. R. An application of operant conditioning tech-
niques to the control of a hyperactive child. In L. P.
Oilman and L. Krasner (Eds.), Case studies in behavior
modification . New York: Holt, Rinehart, and Winston,
Pennypacker, H. S., Koenig, C. H., and Lindsley, 0. R. Hand -
book of the standard behavior chart . Kansas City, KS :
Precision Media, 1972.
Pestalozzi, H. Diary (1774). Translated and excerpted in
J. A. Green, Life and work of Pestalozzi . Baltimore:
Warwick and York, 1912.
Pli:immer, S., Baer, D. M. , and LeBlanc, J. M. Functional
considerations in the use of procedural timeout and an
effective alternative. Journal of Applied Behavior
Analysis , 1977, 10, 689-705.
Premack, D. Reinforcement theory. Nebraska Symposium on
Motivation , 1965, 123-128.
Rachman, S., and Eysenck, H. J. Reply to a "critique and
ref 02rmulation" of behavior therapy. Psychological
Bulletin , 1966, 65_, 165-169.
Rekers , G. A., and Lovaas , 0. I. Behavioral treatment of
deviant sex-role behaviors in a male child. Journal of
Applied Behavior Analysis , 1974, l_r 173-190.
Reynolds, G. S. A primer of operant conditioning . Glenview,
IL: Scott Foresman, 196 8.
Rice, H, K. , and McDaniel, M. W. Operant behavior in vegetative
patients. Psychological Record , 1966, 16_, 279-281.
Rice, H. K., McDaniel, M, W. , Stallings, V. D., and Gatz, M. J.
Operant behavior in vegetative patients II. Psychological
Record , 1967, 1_7, 449-460.
Rickard, H. C, Dignam, P. J., and Horner, R. F. Verbal
manipulation in a psychotherapeutic relationship. Journal
of Clinical Psychology , 1960, 16, 364-367.
Rickard, H. C, and Dinoff, M. A follow-up note on "Verbal
manipulation in a psychotherapeutic relationship. "
Psychological Reports , 1962, 11_, 506,
Rickard, H. C, and Mundy, M. B. Direct manipulation of stut-
tering behavior: An experimental-clinical approach. In
L. P. Ullraan and L. Krasner (Eds.), Case studies in be -
havior modification . New York: Holt, Rinehart, and
Risley, T. R. The effects and side effects of punishing the
autistic behaviors of a deviant child. Journal of Ap-
plied Behavior Analysis , 1968, 1^, 21-34.
Rollings, J. P., Baumeister, A. A., and Baumeister, A. A.
The use of overcorrection procedures to eliminate the
stereotyped behaviors of retarded individuals. Behavior
Modification , 1977, 1, 29-46.
Rothenberg, M. Children with emerald eyes . New York: Dial
Rousseau, J. J. The first and second discourses . Translated
by R. D. Masters. New York: St. Martin, 1964.
Sajwaj , T., Libet, J., and Agras, S. Lemon juice therapy:
The control of life- threatening rumination in a six-
month-old infant. Journal of Applied Behavior Analysi s,
1974, 1_, 557-563.
Schreiber, F. R. Sybil . New York: Warner Books, 19 74.
Shapiro, M. B. The single case of clinical-psychological
research. Journal of General Psychology , 1956, 7_£, 3-23.
Sidman, M. Tactics of scientific research . New York: Basic
Sidman, M. , and Stoddard, L. T. The effectiveness of fading
in programming a simultaneous form discrimination for
retarded children. Journal of the Experimental Analysis
of Behavior, 1967, 10, 3-15.
Skinner, B. F. The behavior of organisms . New York: Apple-
ton-Century-Crof ts , 1938.
Skinner, B. F. Science and human behavior . New York: Free
Solnick, J. v., Rincover, A., and Peterson, C. R. Some deter-
minants of the reinforcing and punishing effects of time-
out. Journal of Applied Behavior Analysis , 1977, 10,
Stoddard, L. T. Behavior shaping: Teaching the retarded .
Five films, NIMH grant, 19 71.
Stoddard, L. T., and Sidman, M. The effects of errors in
children's performance on a circle-ellipse discrimination,
Journal of the Experimental Analysis of Behavior , 1967,
Stokes, T. F., Baer, D. M. , and Jackson, R. L. Programming
the generalization of a greeting response, in four re-
tarded children. Journal of Applied Behavior Analysis ,
1974, 7, 599-610.
Sundel, M. , and Sundel, S. S. Behavior modification in the
human services . New York: Wiley and Sons, 1975.
Tiedmann, D. Observations on the development of the mental
faculties of children . Translated and edited by C.
Murchison and S. Langer. Journal of Genetic Psychology ,
1927, 34, 205-230. (Originally published in 1787.)
Ullman, L. P., and Krasner, L. (Introduction) Case studies
in behavior modification . New York: Holt, Rinehart,
and Winston, 1965.
Watson, J. B. Behaviorism . New York: The People's Institute
Publishing Co., 1924.
Watson, J. B. , and Rayner, R. Conditioned emotional reactions.
Journal of Experimental Psychology , 1920, 3_, 1-14.
Whaley, D. L,, and Malott, R. W. Elementary principles of
behavior . Englewood Cliffs, NJ: Prentice-Hall, 1968.
Williams, C. D, The elimination of tantrum behavior by ex-
tinction procedures. Journal of Abnormal and Social
Psychology , 1959, 59_, 269.
Wolf, J. M., and Anderson, R. M. The multiply handicapped
child. Springfield, IL: Chas . C. Thomas, 1973.
Wolf, M. M. , Birnbrauer, J, S., Williams, T., and Lawler, J,
. A note .on the apparent extinction of the vomiting be-
havior of a retarded child. In L, P. Ullman and L.
Krasner CEds.), Case studies in behavior modification .
New York: Holt, Rinehart, and Winston, 1965.
Wolf, M. M. , Risley, T. R, , and Mees , H. Application of op-
erant conditioning procedures to the behavior problems
of an autistic child. Behavior Research and Therapy,
1964, 1, 305-312. — —
Wolpe, J, ■ Psychotherapy by reciprocal inhibition . Stanford,
CA: Stanford University Press, 1958.
William Hartman was born April 30, 1950, in Chicago. He
grew up in the Chicago area and graduated in 19 6 8 from Deer-
field High School, Deerfield, Illinois.
Mr. Hartman majored in psychology at Oberlin College
(Oberlin, Ohio) , where he received his Bachelor of Arts degree
in 19 72. In late 19 72, he entered the graduate psychology
program at the University of Florida. He studied the experi-
mental analysis of behavior with Dr. H, S, Pennypacker,
stressing applications in higher education, with children, and
with developmen tally disabled individuals. He received his
master's degree in 19 75.
In 1978, while continuing his graduate studies with Dr..
Pennypacker, Mr. Hartman assumed the positions he currently
holds: chief psychologist at the Eunice Kennedy Shriver
Center for Mental Retardation in Waltham, Massachusetts, and
visiting assistant professor of psychology at Northeastern
University. He provides psychological and behavioral assess-
ments and consultation in a community clinic for the develop-
mentally disabled and teaches in a graduate program regarding
Mr, Hartman received his Ph.D. in psychology from the
University of Florida in 1979.
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and._quality ,
as a dissertation for the degree* of Doctpr' of Philo's-aphy.
"Henry S'. Pennyj^acker^''' Chairman
Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Associate Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Mark Goldstein \
Associate Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Jam^s Johnston j
A^_s;siciate Professgr of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Associate Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
..^AiaQvVV ^ YvaavXa-\
Pro^ssor of Foundations of
This dissertation was submitted to the Graduate Faculty
of the Department of Psychology in the College of Liberal
Arts and Sciences and to the Graduate Council, and was ac-
cepted as partial fulfillment of the requirements for the
degree of Doctor of Philosophy.
December, 19 79
Dean, Graduate School